A nurse is reinforcing discharge teaching with a client about how to care for a newly created ileal conduit. Which of the following instructions should the nurse include in the teaching?

Change the ostomy pouch daily.

Empty the ostomy pouch when it is 2/3 full.

Trim the opening of the ostomy seal to be 1/2 inch wider than the stoma.

Apply lotion to the peristomal skin when changing the ostomy pouch.

Answer and Explanation

The Correct Answer is B

Choice A reason: Changing the ostomy pouch daily is not typically necessary. Most pouches can be worn comfortably for several days before needing to be changed. Frequent changes are not only unnecessary but can also irritate the skin around the stoma.

Choice B reason: Emptying the ostomy pouch when it is 2/3 full is recommended to prevent leaks and overfilling, which can lead to discomfort and potential skin irritation. It is important to monitor the fullness of the pouch and empty it regularly to maintain hygiene and comfort.

Choice C reason: Trimming the opening of the ostomy seal to be 1/2 inch wider than the stoma is incorrect. The opening should be cut to match the size of the stoma to ensure a snug fit that prevents leakage and protects the skin around the stoma.

Choice D reason: Applying lotion to the peristomal skin when changing the ostomy pouch is not advised. Lotions or creams can interfere with the adhesive of the ostomy appliance and should be avoided. The peristomal skin should be clean and dry to ensure proper adhesion of the ostomy appliance.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: The Mantoux skin test, also known as the tuberculin skin test, measures the immune response to the tuberculin purified protein derivative injected into the skin. An induration of less than 1 mm is not considered a positive result. However, the size of the induration in the Mantoux test does not indicate whether the person is infectious or not.

Choice B reason: Negative sputum cultures for acid-fast bacillus (AFB) are a strong indication that the client is no longer infectious. Pulmonary tuberculosis is diagnosed and monitored by the presence of AFB in the sputum. When the sputum cultures are negative, it suggests that the client is not excreting the bacteria and is less likely to spread the infection to others.

Choice C reason: While no longer coughing up blood-tinged sputum is a sign of clinical improvement, it does not necessarily mean that the client is no longer infectious. The absence of blood in the sputum may indicate reduced inflammation or healing of lung tissue, but the client could still be capable of transmitting tuberculosis if AFB is present in the sputum.

Choice D reason: The Quantiferon-TB Gold test is a blood test that measures the immune response to Mycobacterium tuberculosis antigens. A positive result indicates that the person's immune system has been exposed to the bacteria, but it does not determine if the person is infectious. The term "positive (negative)" is contradictory and does not provide clear information about the client's infectious status.

A. Decreased urinary output B. Emesis of 250 mL C. Decreased anxiety D. Increased respiratory rate to 26/min

Correct Answer is C

Explanation

Choice A reason: Decreased urinary output is not a direct indicator of morphine's effectiveness in acute heart failure. While morphine can lead to urinary retention, this is generally considered a side effect rather than an intended therapeutic outcome.

Choice B reason: Emesis, or vomiting, of 250 mL is not an indication of morphine's effectiveness. In fact, nausea and vomiting are common side effects of morphine and other opioids. If emesis occurs, it may necessitate further intervention.

Choice C reason: Decreased anxiety is a sign that the morphine is effective. Morphine has anxiolytic properties, meaning it can help alleviate anxiety, which is beneficial in acute heart failure where anxiety can exacerbate symptoms like shortness of breath.

Choice D reason: An increased respiratory rate to 26/min is not an indication of morphine's effectiveness and is a cause for concern. Morphine can depress the respiratory system, and an increased respiratory rate may indicate compensation for hypoxemia or the onset of adverse effects.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is reinforcing discharge teaching with a client about how to care for a newly created ileal conduit. Which of the following instructions should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client who has pulmonary tuberculosis. Which of the following findings should the nurse include as an indication that the client is no longer infectious?

Correct Answer is B

Explanation

A nurse is caring for a client who has acute heart failure and received morphine intravenously 30 minutes ago. Which of the following findings should the nurse identify as an indication that the medication was effective?

Correct Answer is C

Explanation

A nurse is assessing a client who has increased intracranial pressure. The nurse should recognize that which of the following is the first sign of deteriorating neurological status?

A nurse is caring for a client who has developed hives and urticaria following the administration of IV contrast dye after a cardiac catheterization. Which of the following medications should the nurse plan to administer?

A nurse is caring for a client who has a contusion of the brainstem and reports thirst. The client's urinary output was 4,000 mL over the past 24 hours. The nurse should anticipate a prescription for which of the following intravenous (IV) medications?

A nurse is caring for a client who is receiving morphine through a PCA (Patient-Controlled Analgesia) device. Which of the following actions should the nurse take?

A PACU nurse is monitoring the drainage from a client's NG tube following abdominal surgery. Which of the following findings in the first postoperative hour should the nurse report to the provider?

A nurse is planning care for a client who has a radial fracture and a newly placed short arm cast on the left arm. Which of the following findings is the nurse's priority?

A nurse is caring for a client who is postoperative following a complete thyroidectomy. Which of the following findings is the priority for the nurse to report to the provider?

A nurse is preparing a client for a magnetic resonance angiography (MRA). The client is allergic to iodinated contrast dye. Which of the following actions should the nurse plan to take?