A nurse is educating a patient who has an ileal conduit due to bladder cancer.
Which statement from the patient suggests that further instruction is needed?
I need to catheterize the stoma multiple times a day.
I will need to measure my stoma each week.
I will always have to wear a pouch.
I need to clean around the stoma with soap and water.
The Correct Answer is A
Choice A rationale:
The patient does not need to catheterize the stoma multiple times a day. An ileal conduit is a type of urostomy where a small piece of the intestine, called the ileum, is used to create a new passage for urine to leave the body. One end of the ileum is attached to the ureters, and the other end is attached to a small opening in the abdomen, known as a stoma. After the surgery, urine flows from the kidneys, through the ureters and ileal conduit, and out of the stoma. The patient will wear a urostomy pouching system over the stoma to catch and hold the urine. Therefore, the statement “I need to catheterize the stoma multiple times a day” suggests that further instruction is needed because it is not accurate.
Choice B rationale:
The statement “I will need to measure my stoma each week” does not necessarily suggest that further instruction is needed. It is important for patients with an ileal conduit to monitor their stoma regularly for any changes in size, shape, or color, which could indicate complications. However, the frequency of these checks can vary depending on the individual’s condition and the healthcare provider’s instructions.
Choice C rationale:
The statement “I will always have to wear a pouch” is accurate. After the surgery, the patient’s urine will flow from the kidneys, through the ureters and ileal conduit, and out of the stoma. The patient will need to wear a urostomy pouching system over the stoma to catch and hold the urine. Therefore, this statement does not suggest that further instruction is needed.
Choice D rationale:
The statement “I need to clean around the stoma with soap and water” is accurate. It is important for patients with an ileal conduit to keep the skin around the stoma clean to prevent infection and skin irritation. Therefore, this statement does not suggest that further instruction is needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A: Don sterile gloves before inserting the indwelling urinary catheter.
Choice A rationale:
Donning sterile gloves is crucial to prevent infection during the insertion of an indwelling urinary catheter. Maintaining aseptic technique is essential to avoid introducing pathogens into the urinary tract.
Choice B rationale:
Applying an oil-based lubricant to the catheter is not recommended as it can interfere with the sterility of the procedure and potentially cause irritation or infection.
Choice C rationale:
Testing the balloon before insertion is important, but it is not the first step in the process. The priority is to ensure that the nurse is using sterile gloves to maintain aseptic technique.
Choice D rationale:
Using one cotton swab to clean the patient’s urinary meatus is not sufficient for proper aseptic technique. The area should be cleaned thoroughly with appropriate antiseptic solutions and sterile supplies.
Correct Answer is D
Explanation
Choice A rationale:
Prone The prone position, in which a patient lies facedown, is beneficial for patients with pneumonia as it helps shift the fluid away from the back of the lungs, allowing more air to enter. It also improves ventilation in the lungs and reduces the risk of lung collapse. However, this position is not the most effective for maximum lung expansion in pneumonia patients.
Choice B rationale:
Side-lying Lateral positioning, in which the patient lies on one side, is recommended for patients suffering from pneumonia in just one lung. In this position, the pneumatic lung is exposed to a higher blood flow, resulting in greater oxygenation levels and improved lung expansion. This position can also help prevent lung injury by helping regulate pressure and improve aeration.
But again, this is not the most effective position for maximum lung expansion in pneumonia patients.
Choice C rationale:
Supine The supine position, where the patient lies flat on their back, is not the best position for a pneumonia patient. This position can cause the secretions to pool in the lungs, making it harder for the patient to breathe and potentially worsening their condition. Choice D rationale:
Upright Elevating the head of the bed is an effective way to improve lung expansion and oxygenation levels in pneumonia patients. This position also helps eliminate airway obstruction, reduces pressure on the lungs, and promotes drainage of fluids from the lungs. Therefore, the upright position is the most recommended for maximum lung expansion in pneumonia patients.
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