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.
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Related Questions
Correct Answer is C
Explanation
A. Autocratic:
Autocratic leadership involves making decisions without seeking input from others. In this scenario, the charge nurse is eliciting opinions from all group members and organizing a vote, which suggests a more collaborative approach rather than a purely autocratic one.
B. Scientific:
Scientific leadership, often associated with Frederick Taylor's principles of scientific management, involves using data and analysis to make decisions. The scenario does not provide information suggesting a strong emphasis on scientific principles in the decision-making process.
C. Democratic:
Democratic leadership involves including team members in decision-making, seeking their opinions, and often using a voting or consensus-building approach. The charge nurse's approach of eliciting opinions and organizing a vote aligns with democratic leadership.
D. Laizzez-faire:
Laissez-faire leadership involves a hands-off approach, where the leader allows group members considerable freedom to make decisions. In the scenario, the charge nurse is actively seeking input and organizing a vote, which is more indicative of a democratic style rather than laissez-faire.
Correct Answer is B
Explanation
A. Atorvastatin: Atorvastatin is a statin medication used to lower cholesterol levels. It is not known to cause glucose intolerance.
B. Prednisone: Prednisone is a corticosteroid and can cause glucose intolerance by increasing blood glucose levels. Corticosteroids can lead to insulin resistance, impaired glucose utilization, and increased gluconeogenesis.
C. Ranitidine: Ranitidine is an H2 receptor antagonist used to reduce stomach acid production. It is not known to cause glucose intolerance.
D. Guaifenesin: Guaifenesin is an expectorant used to help loosen mucus in the airways. It is not known to cause glucose intolerance.
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