A nurse is assisting with teaching a client who is preoperative for an ileostomy. Which of the following statements
should the nurse include?
"You should expect your stoma to be a purple color."
"The end of the stoma will be painful after this procedure."
"You will have a stoma placed in your right lower abdomen."
"You will have solid stool pass through your stoma."
The Correct Answer is C
The correct answer is c. "You will have a stoma placed in your right lower abdomen."
Choice A reason: The stoma should appear red and moist, similar to the inside of the mouth, not purple.
Choice B reason: The stoma does not have nerve endings, so it should not be painful.
Choice C reason: An ileostomy is typically placed in the right lower abdomen.
Choice D reason: Stool passing through an ileostomy is usually liquid to pasty, not solid.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Dark-colored urine can be a sign of dehydration or the presence of certain substances in the urine, such as blood or bile, but it is not typically associated with urinary retention.
Choice B reason: Leakage of urine, or overflow incontinence, can occur in urinary retention when the bladder is overfilled and the pressure within the bladder exceeds urethral resistance. This can lead to involuntary release of urine.
Choice C reason: Blood in the urine, or hematuria, can indicate various conditions, including infections, stones, or tumors, but it is not a common finding specifically associated with urinary retention.
Choice D reason: Cloudy urine may suggest the presence of phosphates (a normal occurrence in alkaline urine), infection, or the presence of pus (pyuria). While it could be associated with a urinary tract infection that might lead to urinary retention, cloudy urine itself is not a direct indicator of urinary retention.
Correct Answer is C
Explanation
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.
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