A nurse is reinforcing teaching about ileostomy care with a client. The nurse should recognize which of the following statements by the client indicates a need for further teaching?

"I will be certain to take enteric-coated medications."

"I will empty my pouch when it becomes one third full."

"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 A

A.   Enteric-coated medications are designed to dissolve in the small intestine rather than the stomach. This is important for ileostomy patients because medications that dissolve in the stomach may be poorly absorbed or can cause irritation to the stoma or the small intestine.
B.   It's recommended to empty the ostomy pouch when it's about one-third to half full to prevent leakage or discomfort.
C.   How often the pouch system needs to be changed can vary depending on individual factors such as skin sensitivity, output consistency, and the type of pouch system used. Generally, changing the pouch system every 3-7 days is recommended.
D.   High fiber foods can increase stool output and gas production, which can be challenging for individuals with an ileostomy. However, fiber is important for overall digestive health, so moderation rather than avoidance is typically recommended.

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Correct Answer is D

Explanation

A. Protein intake, especially animal protein (such as meat and dairy), can increase the excretion of calcium and other minerals into the urine, potentially leading to the formation of certain types of kidney stones (like calcium stones). Therefore, clients with a history of kidney stones are generally advised to moderate their intake of animal protein.
B. Some types of tea, particularly black tea, contain oxalates, which are substances that can contribute to the formation of calcium oxalate kidney stones in susceptible individuals. Therefore, clients with kidney

stones may be advised to limit their intake of tea, especially if they have a history of calcium oxalate stones.
C. High dietary sodium intake can increase calcium excretion in the urine, which may lead to the formation of calcium-containing kidney stones. Therefore, clients with kidney stones are often advised to reduce their sodium intake to help prevent stone formation.
D. Adequate fluid intake, primarily in the form of water, is crucial for preventing kidney stones. Increased water intake helps dilute urine and reduces the concentration of stone-forming substances, making it less likely for crystals to form and grow into stones. The goal is typically to produce at least 2 to 2.5 liters (about 8 to 10 cups) of urine per day.

A. Perform a blind finger sweep. B. Begin the Heimlich maneuver. C. Turn the client to the side. D. Tilt the head and lift the chin.

Correct Answer is B

Explanation

A. Performing a blind finger sweep involves inserting a finger into the client's mouth to try and remove an obstruction. This action is not recommended because it can push the obstruction further down the airway, potentially worsening the situation and causing the client to choke.
B. The Heimlich maneuver (abdominal thrusts) is a technique used to clear an obstructed airway in conscious adults. It involves applying sudden upward pressure on the abdomen, between the navel and ribcage, to force air from the lungs to dislodge the obstruction.
C. Turning the client to the side is typically done if the client is unconscious and not breathing normally (recovery position). This position helps maintain a clear airway by allowing any fluids or vomit to drain out of the mouth and prevent obstruction.
D. Tilting the head and lifting the chin is part of the head-tilt, chin-lift maneuver used to open the airway. This maneuver is used when a client is unconscious or unresponsive but breathing. It helps to keep the airway open by lifting the tongue away from the back of the

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A nurse is reinforcing teaching about ileostomy care with a client. The nurse should recognize which of the following statements by the client indicates a need for further teaching?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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