A client diagnosed with ulcerative colitis has a new ileostomy. Which statement indicates the client needs more teaching concerning the ileostomy?
"I should clean the stoma site with warm water and mild soap."
"I can continue to participate in physical activities and exercise."
"I should avoid eating high-fiber foods."
"I should change the ostomy bag every day."
The Correct Answer is D
A. Cleaning the stoma site with warm water and mild soap is appropriate and the correct way to maintain stoma hygiene. No harsh chemicals or abrasive materials should be used.
B. It is safe for the client to continue participating in physical activities and exercise, as long as they feel comfortable and take necessary precautions to protect the stoma.
C. Clients with an ileostomy are generally advised to avoid high-fiber foods, especially right after surgery, to reduce the risk of blockages.
D. The ostomy bag should typically be changed every 3 to 7 days, depending on the type of bag used and the amount of output. Changing it every day is unnecessary unless there are signs of leakage or skin irritation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Tympany upon chest percussion is typically associated with the presence of air, such as in cases of pneumothorax or gastric distention. It is not a typical finding in pneumonia.
B. Unequal pupils (anisocoria) are not a common symptom of pneumonia and may indicate a neurological issue rather than a respiratory infection.
C. Hypertension is not a characteristic finding in community-acquired pneumonia. Pneumonia may cause changes in blood pressure, but hypotension or normal blood pressure is more likely.
D. Confusion is a common finding in older adults with pneumonia. This can be due to factors such as hypoxia, dehydration, or infection-related changes in mental status, often referred to as "pneumonia delirium" or "acute confusion." Older adults are particularly susceptible to cognitive changes due to infection.
Correct Answer is C
Explanation
A. Administering a broad-spectrum antibiotic is not the first action in this case. The first priority is to assess the situation and obtain a culture of the drainage to identify any infection before initiating antibiotics.
B. While notifying the healthcare provider is important, it is more important to take an initial action by obtaining a culture specimen. Waiting without taking action could delay appropriate care.
C. The best first action is to obtain a culture of the drainage to identify any potential infection, apply a sterile dressing, and continue to monitor the site for further signs of infection. Culturing the drainage helps guide the appropriate treatment.
D. Removing the sutures is not the appropriate action. The sutures should not be removed unless there is clear indication, as this could disrupt the integrity of the catheter placement.
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