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 A
Explanation
A. "Eat four small meals each day":
Smaller, more frequent meals reduce gastric distension and lower gastric pressure, which decreases reflux of stomach contents into the esophagus. Large meals increase intra-abdominal pressure and worsen GERD symptoms.
B. "Sleep on your left side":
Sleeping on the left side may reduce symptoms of GERD for some individuals. This position can keep the stomach below the esophagus, minimizing reflux. However, individual preferences and comfort should be considered.
C. "Wait to go to bed for 1 hour after eating":
This instruction helps reduce the risk of reflux while lying down. Waiting after eating allows gravity to aid in digestion and reduces the likelihood of stomach contents backing up into the esophagus during sleep.
D. "Drink milk to soothe your stomach":
While milk might provide temporary relief for some people by neutralizing stomach acid, it can stimulate acid production, potentially exacerbating GERD symptoms in the long run. Therefore, it's not a recommended solution for managing GERD.
Correct Answer is D
Explanation
A. Avoiding eating at fast food restaurants is not a specific preventive measure for hepatitis A transmission. The primary mode of transmission for hepatitis A is through the fecal-oral route, often due to contaminated food or water.
B. Avoiding serving raw foods is a reasonable precaution as raw or undercooked shellfish and contaminated fruits and vegetables can be a source of hepatitis A transmission. However, practicing effective hand hygiene is a more general and fundamental preventive measure.
C. Wearing barrier protection during vaginal intercourse is not directly related to the prevention of hepatitis A. Hepatitis A is primarily transmitted through the fecal-oral route, and sexual transmission is not a common mode for this virus.
D. Practicing effective hand hygiene is a key strategy for preventing the transmission of hepatitis A. Proper handwashing with soap and water, especially after using the bathroom and before handling food, can help reduce the risk of contamination and transmission of the virus.
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