A nurse is reinforcing teaching for a client who has a new ascending colostomy. Which of the following comments by the client indicates an understanding of the teaching?
I will irrigate the colostomy every day.
I will notify my doctor if the stoma starts to look purple.
I will no longer be able to eat nuts.
I should expect my stool to be formed.
The Correct Answer is B
I will notify my doctor if the stoma starts to look purple
The comment by the client indicating an understanding of the teaching is option B: "I will notify my doctor if the stoma starts to look purple."
I will irrigate the colostomy every day in (option A) is incorrect. Colostomy irrigation is not necessary for all clients with an ascending colostomy. It is important to individualize the teaching based on the client's specific needs and healthcare provider's instructions. Routine colostomy irrigation may not be required, and the client should follow the healthcare provider's guidance regarding colostomy care.
I will no longer be able to eat nuts in (option C) is incorrect. There are generally no dietary restrictions for clients with an ascending colostomy, unless otherwise advised by their healthcare provider. It is important to provide accurate information about dietary considerations, which may vary based on individual circumstances and healthcare provider recommendations.
I should expect my stool to be formed in (option D) is incorrect. With an ascending colostomy, the stool is typically liquid or semi-liquid as it comes from the ascending colon, which is higher in the gastrointestinal tract. The stool is not expected to be formed. It is important for the client to have appropriate expectations regarding stool consistency to manage their colostomy effectively.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Potassium is an essential electrolyte that plays a crucial role in various bodily functions. However, for individuals with an electrolyte imbalance, it is often necessary to limit their potassium intake. Among the options provided, baked chicken breast is the lowest in potassium. Cantaloupe is relatively high in potassium. A cup of diced cantaloupe contains about 430 mg of potassium.
Sweet potatoes are known for their high potassium content. A medium-sized sweet potato with skin contains about 542 mg of potassium.
Orange juice also contains a moderate amount of potassium. An 8-ounce serving of orange juice typically contains around 450 mg of potassium.
Chicken breast is naturally low in potassium compared to fruits and vegetables. It contains about 260 mg of potassium per 4-ounce serving.
Therefore, among the given options, the baked chicken breast is the lowest in potassium and would be the most suitable choice for a client with an electrolyte imbalance requiring a low-potassium diet.
Correct Answer is C
Explanation
When removing the dressing and cleaning the wound, it is important to start from the center of the wound and work toward the outer edges. This technique helps prevent contamination of the wound by minimizing the risk of dragging bacteria or debris from the surrounding skin into the wound.
The other options listed are not recommended for this specific procedure:
When removing the tape, it is generally recommended to pull it parallel to the skin surface rather than pulling it from the center of the dressing. This technique reduces the risk of causing trauma or disrupting the wound.
While it is important to maintain an aseptic technique during dressing changes, wearing sterile gloves is not necessary for a wet-to-dry dressing change. Clean, non-sterile gloves are typically sufficient for this procedure, as the dressing material itself is not sterile.
In a wet-to-dry dressing change, the dressing is typically applied moist and allowed to dry over time. Therefore, moistening the dressing before removal is not necessary. The primary goal is to remove the dry dressing, which may adhere to the wound bed, and then clean the wound before applying a fresh dressing.
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