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 D
Explanation
Choice A reason: Sterile gloves are not required for inserting an NG tube; clean gloves are sufficient as the nasal
cavity is not a sterile environment.
Choice B reason: The client should not be asked to cough while inserting the NG tube as this could disrupt the placement process. Instead, the client may be asked to swallow to facilitate the passage of the tube.
Choice C reason: Placing the client into a left lateral position is not the standard position for NG tube insertion. The
client should be in an upright or semi-Fowler's position to aid in the insertion process.
Choice D reason: Determining the length of the NG tube to be inserted is a crucial step to ensure that the tube
reaches the stomach without coiling in the esophagus or extending into the small intestine.
Correct Answer is D
Explanation
Choice A reason: Choosing sugar-sweetened beverages is not recommended for clients with kidney stones as they
can lead to weight gain and increase the risk of stone formation.
Choice B reason: Limiting calcium intake is not generally advised for kidney stone prevention; in fact, adequate
calcium intake is important to bind oxalate in the gut.
Choice C reason: Drinking only 1 liter of fluid each day is insufficient; it is recommended to drink enough water to produce at least 2.5 liters of urine daily to prevent kidney stones.
Choice D reason: Filtering urine each day can help to catch stones that are passed, which can then be analyzed to determine their composition and guide further treatment.
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