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 B
Explanation
Choice A reason: Aluminum-containing antacids are more likely to cause constipation rather than diarrhea.
Choice B reason: Magnesium-containing antacids can cause diarrhea because magnesium can act as an osmotic laxative, drawing water into the intestines and increasing peristalsis.
Choice C reason: While antibiotics can disrupt the gut flora and potentially cause diarrhea, they are not the best
answer when compared to magnesium-containing antacids specifically known for this side effect.
Choice D reason: Anticholinergics/antispasmodics typically reduce gastrointestinal motility, which would more likely lead to constipation instead of diarrhea.
Choice E reason: Opioid narcotics are known to cause constipation due to reduced gut motility, not diarrhea
Correct Answer is D
Explanation
Choice A reason: Decreased bowel sounds are not typically associated with diarrhea. Diarrhea usually presents with
increased bowel sounds due to hyperactive gastrointestinal motility.
Choice B reason: A rigid abdomen may suggest an acute abdomen that requires immediate medical attention, not a common finding in uncomplicated cases of diarrhea.
Choice C reason: Hypothermia is not a common finding in diarrhea. Fever may occur if the diarrhea is infectious in
origin.
Choice D reason: Dehydration is a common finding in patients with prolonged diarrhea due to excessive loss of fluids
and electrolytes.
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