A nurse is assisting with evaluating a newly licensed nurse drain an ileostomy bag for a client. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?
Wears sterile gloves to drain the ileostomy bag
Cleans the end of the ileostomy pouch before clamping
Empties the ileostomy bag when it is three-fourths full
Washes the skin surrounding the client's ileostomy with hot water
The Correct Answer is B
A. Wears sterile gloves to drain the ileostomy bag: Clean gloves are appropriate. Sterile gloves are unnecessary unless performing an invasive procedure.
B. Cleans the end of the ileostomy pouch before clamping: Cleaning the end of the pouch helps prevent skin irritation and controls odor. This reflects proper hygiene.
C. Empties the ileostomy bag when it is three-fourths full: The bag should be emptied when it is one-third to one-half full to prevent leaks or separation from the skin.
D. Washes the skin surrounding the client's ileostomy with hot water: Warm water is recommended. Hot water may irritate the skin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Cleanse the labia: This must be done after donning sterile gloves to maintain asepsis.
B. Don sterile gloves: Sterile technique is required after opening the kit. Gloves must be put on before touching sterile items like swabs or catheters.
C. Cleanse the meatus: This occurs after sterile gloves are worn and before catheter insertion.
D. Lubricate the catheter: Catheter lubrication happens after gloves are on and after cleaning the area.
Correct Answer is C
Explanation
A. Dairy products: Dairy is generally not known to irritate the bladder and is usually well tolerated.
B. Fresh vegetables: Fresh vegetables are high in fiber and beneficial; they are not bladder irritants.
C. Caffeinated beverages: Caffeine acts as a bladder stimulant and diuretic, increasing urgency and incontinence.
D. Red meat: Red meat is not a common bladder irritant, although it may affect overall health.
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