A nurse is teaching a client who is preoperative for an ileostomy. Which of the following statements should the nurse include?

You will have a stoma placed in your right lower abdomen.

The end of the stoma will be painful after this procedure.

You should expect your stoma to be a purple color.

You will have solid stool pass through your stoma.

Answer and Explanation

The Correct Answer is AANDD

Choice A rationale

An ileostomy involves creating a stoma, or opening, in the abdominal wall. The location of the stoma is typically in the right lower abdomen.

Choice B rationale

The end of the stoma should not be painful after the procedure. If the patient experiences pain, it could indicate a complication and should be reported to the healthcare provider.

Choice C rationale

The patient should not expect the stoma to be a purple color. A healthy stoma should be red or pink. A purple stoma could indicate a lack of blood flow, which is a serious issue that needs immediate medical attention.

Choice D rationale

After an ileostomy, the patient will have liquid or semi-liquid stool pass through the stoma. This is because the large intestine, which normally absorbs water and forms solid stool, is bypassed or removed in the procedure.

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Correct Answer is C

Explanation

Rationale:

When administering multiple liquid medications through an NG tube, it’s important to administer each medication separately to prevent drug interactions. After each medication, the NG tube should be flushed with 30 mL of water to ensure that the medication has been fully administered and to prevent the tube from becoming clogged.

A. Full thickness skin loss with visible bone. B. Intact skin with localized erythema. C. Partial-thickness skin loss with red tissue. D. Full thickness skin loss with visible adipose tissue.

Correct Answer is D

Explanation

Choice A rationale

Full thickness skin loss with visible bone is not described in the question. This would be a description of a stage IV pressure ulcer, which involves full thickness tissue loss with exposed bone, tendon, or muscle.

Choice B rationale

Intact skin with localized erythema is not described in the question. This would be a description of a stage I pressure ulcer, which involves intact skin with non-blanchable redness of a localized area usually over a bony prominence.

Choice C rationale

Partial-thickness skin loss with red tissue is not described in the question. This would be a description of a stage II pressure ulcer, which involves partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.

Choice D rationale

Full thickness skin loss with visible adipose tissue is the condition described in the question. This would be a description of a stage III pressure ulcer, which involves full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed.

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A nurse is teaching a client who is preoperative for an ileostomy. Which of the following statements should the nurse include?

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Naxlex Comprehensive Predictor Exams

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