A nurse is developing a teaching plan for a client who has an Ileostomy and will require stoma care. Which of the following Information should the nurse include?
Clean the peristomal skin four times a day.
Hold pressure on the skin barrier for 10 to 15 sec to secure the seal.
Empty the pouch when it is 1/3 Full
Expect firm fecal content.
The Correct Answer is C
A. Clean the peristomal skin four times a day:
While keeping the peristomal skin clean is essential, cleaning it four times a day might be excessive and could lead to skin irritation. Typically, cleansing the area when changing the pouch or as needed is sufficient.
B. Hold pressure on the skin barrier for 10 to 15 seconds to secure the seal:
Applying gentle pressure upon application can assist in securing the seal, but the duration might vary based on the manufacturer's recommendations. It's important not to overly press or manipulate the barrier excessively, as it could cause skin trauma.
C. Empty the pouch when it is 1/3 full:
This is the correct advice. Regularly emptying the pouch prevents leakage and ensures the pouch does not become too heavy or cause skin irritation from weight or pressure.
D. Expect firm fecal content:
With an ileostomy, the fecal content tends to be more liquid compared to other types of ostomies like colostomies, so expecting firm fecal content might not be accurate for this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Lactulose is not used to decrease potassium levels. It is a laxative that works by drawing water into the colon, softening stools and promoting bowel movements.
B. Lactulose is used to decrease ammonia levels in clients with cirrhosis. Ammonia is a byproduct of protein metabolism, and when the liver is compromised, it may not effectively convert ammonia into urea, leading to elevated ammonia levels in the bloodstream. Lactulose helps reduce ammonia absorption in the colon.
C. Lactulose does not decrease glucose levels significantly. It is not primarily used as an antidiabetic medication.
D. Lactulose does not affect bicarbonate levels significantly. It primarily targets ammonia reduction in clients with cirrhosis.
Correct Answer is C
Explanation
A. Steatorrhea:
Steatorrhea refers to the presence of excessive fat in the stool. If a healthcare provider suspects malabsorption or fat digestion issues, they might order a fecal fat test to assess the amount of fat in the stool. This test is different from a guaiac fecal occult blood test (gFOBT), which is designed to detect blood.
B. Parasites:
The detection of parasites in the stool involves specific testing methods, such as microscopic examination of stool samples or specialized tests aimed at identifying the presence of parasitic organisms. A guaiac fecal occult blood test is not designed to detect parasites; its primary purpose is to identify occult (hidden) blood.
C. Blood:
A stool test for guaiac is specifically designed to detect the presence of occult (hidden) blood in the stool. The guaiac test involves placing a small sample of stool onto a test card containing guaiac, and a color change indicates the presence of blood. This test is commonly used to screen for gastrointestinal bleeding.
D. Bacteria:
Detecting bacteria in the stool typically involves stool cultures or specific tests designed to identify bacterial infections or imbalances in the gut microbiota. The guaiac test is not intended for detecting bacteria; its primary focus is on identifying the presence of blood in the stool.
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