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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. 7.8%
An HbA1c value of 7.8% indicates an average blood sugar level over the past 2-3 months that is higher than the optimal range. This suggests that the client may not be achieving optimal glucose control.
B. 8.5%
An HbA1c value of 8.5% also indicates elevated average blood sugar levels over the past few months. This value suggests poorer control of diabetes, and adjustments to the management plan may be needed.
C. 10%
An HbA1c value of 10% indicates higher average blood sugar levels, signifying inadequate control of diabetes. This value suggests a need for intervention and modification of the treatment plan to achieve better glucose management.
D. 6.3%
An HbA1c value of 6.3% is considered a relatively good indicator of glucose control. This value suggests that the client has been successful in maintaining lower average blood sugar levels over the past 2-3 months, reflecting effective diabetes management.
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.
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