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","C","E","F"]
Explanation
Mucous membranes pink, skin warm and dry: These are normal findings and do not require follow-up.
Coughing and clearing throat when eating: This suggests possible aspiration, especially concerning in post-stroke clients.
Voice hoarse after swallowing: A hoarse voice post-swallow is a red flag for aspiration risk and should be evaluated promptly.
Temperature 38 °C (100.4°F): This is a low-grade fever and not immediately concerning without other symptoms.
Bilateral breath sounds with wheezing heard in upper lobes: New-onset wheezing indicates possible airway inflammation, aspiration pneumonia, or respiratory distress.
Oxygen saturation 88% on room air: An O₂ saturation below 90% indicates hypoxemia, requiring immediate attention and supplemental oxygen.
Correct Answer is A
Explanation
A. Alternate the client's liquids and food during meals: This helps clear the throat and prevent food accumulation, reducing the risk of aspiration.
B. Turn on the client's television during meals: Distractions should be minimized so the client can concentrate on safe swallowing.
C. Instruct the client to sit their head back while swallowing: This increases the risk of aspiration; instead, the chin-tuck method is often safer.
D. Elevate the client’s head of bed to 45° during meals: The head should be elevated to at least 90° during meals to reduce aspiration risk.
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