A nurse is providing discharge teaching to a client who has an ileostomy. Which of the following client statements indicates an understanding of the teaching?

"I will empty my bag when it is full."

"I will take a laxative when I'm constipated."

"I will expect my stools to be loose."

"I will eat a high-fiber diet."

Answer and Explanation

The Correct Answer is C

An ileostomy is a surgical opening in the abdomen that connects the end of the small intestine (ileum) to a pouch or bag on the outside of the body. The ileostomy bypasses the large intestine (colon) and rectum, which normally absorb water and form solid stools. Therefore, the client should expect their stools to be loose and watery. The client should empty their bag several times a day, not when it is full, to prevent leakage and skin irritation. The client should avoid laxatives, which can cause dehydration and electrolyte imbalance. The client should also avoid high-fiber foods, which can cause blockage or irritation of the ileostomy.

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Correct Answer is A

Explanation

A platelet count of 95,000/mm is below the normal range of 150,000 to 400,000/mm and indicates thrombocytopenia, which increases the risk of bleeding during surgery. The nurse should report this value to the surgeon and anticipate interventions such as transfusion of platelets or postponement of surgery. The other values are within normal limits and do not require immediate attention.

A. "You should get a second opinion regarding the procedure." B. "You will be cancer-free if you have the procedure." C. "I can give you a list of other people who had the same procedure." D. I can give you additional information about the procedure."

Correct Answer is D

Explanation

A mastectomy is a surgical removal of one or both breasts, usually done to treat breast cancer. The nurse should respect the client's autonomy and provide factual information about the procedure, its benefits and risks, and possible alternatives . The nurse should also assess the client's readiness to learn, address any concerns or fears, and offer emotional support . Telling the client to get a second opinion may imply that the nurse does not trust the surgeon or doubts the necessity of the procedure.

Telling the client that they will be cancer-free if they have the procedure may be false or misleading, as there may be residual cancer cells or recurrence after surgery. Giving the client a list of other people who had the same procedure may violate confidentiality and may not be helpful or relevant to the client's situation.

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A nurse is providing discharge teaching to a client who has an ileostomy. Which of the following client statements indicates an understanding of the teaching?

Nursing Test Bank

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