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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Ground beef is often included in a soft diet as it can be cooked to a tender consistency that is easy
to chew and swallow.
Choice B reason: Raw vegetables are generally not included in a soft diet because they can be difficult to chew and may pose a risk for individuals with certain digestive or dental issues.
Choice C reason: Fruit with the skin is typically not recommended for a soft diet as the skin can be tough and fibrous,
making it harder to chew and digest.
Choice D reason: High-fiber cereals are usually avoided in a soft diet because they may contain whole grains or nuts
that are hard and could be challenging to chew.
Correct Answer is B
Explanation
Choice A reason: Infusing 0.9% sodium chloride is not the immediate action to take when a transfusion reaction is suspected. The priority is to stop the transfusion and address the reaction.
Choice B reason: Obtaining a blood sample from the client is necessary to perform laboratory tests to confirm the transfusion reaction and to identify the cause.
Choice C reason: Returning the unit of blood to the blood bank is done after the transfusion has been stopped and the reaction has been addressed. It is important for the blood bank to know about the reaction to investigate the cause.
Choice D reason: Notifying the charge nurse is important, but the first action should be to stop the transfusion and maintain the client's safety. The charge nurse can then assist with the subsequent steps.
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