A nurse is providing discharge teaching for a client who had a partial colectomy 2 days ago. Which of the following information should the nurse include in the teaching?
"Place an aspirin in your ostomy pouch to control odor."
"Your ostomy should start functioning in five days."
"Empty your ostomy pouch when it becomes a third to halfway full."
"Notify your provider if your stoma becomes dark red:"
The Correct Answer is C
A. "Place an aspirin in your ostomy pouch to control odor.": Aspirin should never be placed in an ostomy pouch, as it can damage the pouch material and irritate the stoma. Deodorizers or dietary adjustments are safer alternatives for odor control.
B. "Your ostomy should start functioning in five days.": An ostomy typically begins functioning within 2 to 4 days postoperatively, depending on bowel motility. Waiting five days without output could indicate an obstruction or ileus, requiring medical evaluation.
C. "Empty your ostomy pouch when it becomes a third to halfway full.": Keeping the pouch from becoming too full prevents leaks, discomfort, and excessive pressure on the stoma. This practice helps maintain skin integrity and ostomy function.
D. "Notify your provider if your stoma becomes dark red.": A dark red stoma is normal and indicates good blood supply. However, a stoma that turns pale, dusky, or black requires immediate medical attention, as it suggests compromised circulation and possible necrosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. 150 mL of greenish yellow NG drainage: This amount and color of drainage are expected after abdominal surgery, as bile-stained gastric contents can be present. It does not indicate a complication that requires provider notification.
B. Client requests medication for nausea: Nausea is a common postoperative symptom, often managed with antiemetics. While it should be addressed, it is not an urgent finding that requires immediate provider notification.
C. Urinary output of 250 mL over past 12 hr: Oliguria, defined as urine output less than 30 mL/hr (or less than 400 mL in 24 hr), suggests inadequate renal perfusion, possibly due to hypovolemia or acute kidney injury. This finding requires prompt provider notification.
D. Hypoactive bowel sounds: Reduced bowel activity is common after abdominal surgery due to anesthesia and opioid use. While monitoring is necessary, hypoactive sounds alone are not an urgent concern unless accompanied by other signs of ileus or obstruction.
Correct Answer is ["B","D","E"]
Explanation
- "The iron supplement might cause my stools to be black.": This statement is correct as one of the common side effects of iron supplementation is darkening of the stools. This occurs due to the unabsorbed iron and is generally harmless, but clients should be educated about this to avoid confusion with gastrointestinal bleeding.
- "I should increase green leafy vegetables in my diet.": Green leafy vegetables are excellent sources of iron, particularly non-heme iron, which can help improve the client's iron levels. Encouraging a diet rich in iron-rich foods is essential for effective management of iron deficiency anemia, especially for clients on a vegan diet.
- "I will take my iron supplement 1 hour before a meal.": Taking iron supplements on an empty stomach enhances absorption. Clients should be instructed to take the supplement ideally 1 hour before meals or 2 hours after meals for optimal efficacy, unless gastrointestinal discomfort occurs.
- "I should expect to have swelling in my feet.": This statement is not appropriate. Swelling in the feet may indicate fluid retention or other medical issues that should be reported. It is not a typical or expected side effect of iron supplementation or iron deficiency anemia.
- "The iron supplement might cause ringing in my ears.": Ringing in the ears (tinnitus) is not a common side effect of iron supplements. If a client experiences this symptom, it may be related to other factors or medications and should be investigated further.
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