A nurse is assisting with evaluating a newly licensed nurse who is draining 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
Washes the skin surrounding the client's ileostomy with hot water
Cleans the end of the ileostomy pouch before clamping
Empties the ileostomy bag when it is three-fourths full
The Correct Answer is C
Choice A reason: Wearing sterile gloves is not necessary when draining an ileostomy bag as this is not a sterile procedure. Clean gloves are typically used.
Choice B reason: Washing the skin surrounding the ileostomy with hot water is not recommended as it can cause
irritation. Lukewarm water should be used, and the area should be patted dry.
Choice C reason: Cleaning the end of the ileostomy pouch before clamping is important to maintain hygiene and
prevent contamination when draining the bag.
Choice D reason: The ileostomy bag should be emptied when it is one-third to one-half full to prevent leakage and ensure comfort for the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Muscle weakness is a common symptom of hypokalemia, as potassium is crucial for muscle function and nerve signals that stimulate muscle contractions.
Choice B reason: Cerebral edema is not a typical manifestation of hypokalemia. It is more commonly associated with other conditions such as brain injury or disease.
Choice C reason: Hypertension is generally not a direct result of hypokalemia. In fact, low potassium levels can sometimes lead to lower blood pressure.
Choice D reason: Hyperactive bowel sounds are not specifically associated with hypokalemia. Diarrhea can cause fluid loss leading to hypokalemia, but the condition itself does not cause hyperactive bowel sounds.
Correct Answer is C
Explanation
Choice A reason: The reservoir bag on a nonrebreather mask should not collapse with exhalation. It is designed to maintain a continuous flow of oxygen and reserve a volume of oxygen for the patient to inhale with each breath.
Choice B reason: While high-flow oxygen can dry a patient's mucous membranes, a nonrebreather mask typically has a high oxygen flow rate, and humidification can be used to prevent drying.
Choice C reason: A nonrebreather mask must fit snugly over the patient's face to ensure that the highest concentration of oxygen is delivered and that there is minimal dilution with room air.
Choice D reason: A nonrebreather mask is used to deliver high-flow oxygen, not low-flow. It is designed to provide a high concentration of oxygen, typically around 60% to 90% FiO2.
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