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. "Consume a low-fiber diet.": A high-fiber diet promotes bowel movement regularity.
B. "Increase your daily fluid intake.": Fluids help soften stool and promote bowel movements.
C. "Reduce your daily activity.": Physical activity stimulates peristalsis and helps relieve constipation.
D. "Try to defecate at different times of the day.": Establishing a regular time (especially after meals) promotes bowel training.
Correct Answer is D
Explanation
A. "The end of the stoma will be painful after this procedure": The stoma has no nerve endings, so it should not be painful.
B. "You should expect your stoma to be a purple color.": A healthy stoma is pink to red; purple or dark color suggests poor perfusion and requires immediate attention.
C. "You will have solid stool pass through your stoma.": An ileostomy produces liquid to semi-liquid stool, as the large intestine (which absorbs water) is bypassed.
D. "You will have a stoma placed in your right lower abdomen.": An ileostomy is usually created from the ileum and placed in the right lower quadrant.
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