A nurse is providing teaching about ileostomy care to a client. Which of the following statements by the client indicates a need for further teaching?

“I will empty my pouch when it becomes 1/3 full.”

“I will be careful to take enteric-coated medications.”

“I will change my entire pouch system at least weekly.”

“I will use caution when eating high-fiber foods.”

Answer and Explanation

The Correct Answer is B

A. Emptying the pouch when it becomes 1/3 full is appropriate and helps prevent leakage and odor. This statement shows understanding of proper pouch management.

B. Enteric-coated medications can be problematic for clients with an ileostomy as they may not dissolve properly in the digestive system, potentially leading to decreased absorption. The client should be aware that these medications may not be suitable for their condition.

C. Changing the entire pouch system at least weekly is a common recommendation to maintain hygiene and skin integrity. This indicates the client understands the need for regular pouch maintenance.

D. Caution when eating high-fiber foods is important, as these foods can cause blockages in the ileostomy. This statement reflects the client’s awareness of dietary considerations for managing their ileostomy.

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Correct Answer is A

Explanation

A. Serous drainage is clear and watery, which is typical during the early stages of healing and indicates normal wound healing.

B. Purulent drainage is thick and may appear yellow, green, or brown, indicating infection.

C. Serosanguineous drainage is a mix of serous fluid and small amounts of blood, typically pink in color, and is seen in wounds that are healing.

D. Sanguineous drainage is primarily blood, indicating fresh bleeding from a wound.

A. Sanguineous B. Serosanguineous C. Serous D. Purulent

Correct Answer is B

Explanation

A. Sanguineous drainage is characterized by bright red blood; it indicates fresh bleeding and does not include watery components.

B. Serosanguineous drainage is a combination of clear, watery fluid and blood, often appearing light pink to red. The description of watery red drainage fits this category, making it the correct choice.

C. Serous drainage is clear, pale yellow fluid without blood, indicating a non-bloody exudate. It does not match the description of watery red drainage.

D. Purulent drainage is thick, opaque, and often yellow, green, or brown due to the presence of pus and infection. It does not apply here as the drainage is described as watery red.

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A nurse is providing teaching about ileostomy care to a client. Which of the following statements by the client indicates a need for further teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client's wound dressing, and observes a clear watery drainage. The nurse should document this drainage as which of the following?

Correct Answer is A

Explanation

A nurse is assessing a client's wound dressing and observes a watery red drainage. The nurse should document this drainage as which of the following?

Correct Answer is B

Explanation

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