A nurse is reinforcing teaching with a client who has a new ileostomy.
Which of the following statements by the client indicates an understanding of the teaching?
"I will need to empty the bag every 4 to 6 hours.”.
"I will use moisturizing soap to clean around the stoma before applying the bag.”.
"I will cut the wafer opening one-fourth of an inch larger than the stoma.”.
"I will use a skin sealant before I apply the bag.”. . . .
The Correct Answer is C
Choice A rationale
Emptying the ileostomy bag every 4 to 6 hours is incorrect as the frequency depends on the individual's output, which can be higher, requiring more frequent emptying.
Choice B rationale
Using moisturizing soap to clean around the stoma is not recommended as it can interfere with the adhesion of the wafer. Mild, non-moisturizing soap should be used instead.
Choice C rationale
Cutting the wafer opening one-fourth of an inch larger than the stoma is correct as it allows for proper fitting and prevents constriction of the stoma, reducing the risk of skin irritation.
Choice D rationale
Using a skin sealant before applying the bag is recommended to protect the skin and improve the adhesion of the ostomy appliance. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
The flu shot provides protection for about one year. It is recommended to receive the flu shot annually for continued protection, especially as flu strains can vary each year.
Choice B rationale
The hepatitis B vaccine does not require annual administration. It is typically given in a series of shots over a few months and provides long-term protection.
Choice C rationale
Performing a breast self-exam a week after each menstrual period is ideal because hormonal changes that cause breast tissue to be tender or lumpy will be minimal, making it easier to detect any unusual changes.
Choice D rationale
Testicular self-exams are recommended to be done monthly, not every 6 months. Regular monthly exams help in early detection of any changes or abnormalities.
Correct Answer is A
Explanation
Choice A rationale
Kussmaul respirations are deep, labored breathing patterns associated with metabolic acidosis, commonly seen in severe hyperglycemia and diabetic ketoacidosis.
Choice B rationale
Diaphoresis, or sweating, is typically associated with hypoglycemia rather than hyperglycemia. Hyperglycemia often leads to dehydration and dry skin.
Choice C rationale
Urinary ketones are typically present in cases of severe hyperglycemia and diabetic ketoacidosis. Absence of urinary ketones does not indicate hyperglycemia.
Choice D rationale
Chvostek's sign, a twitching of facial muscles, is indicative of hypocalcemia rather than hyperglycemia. It is not a reliable indicator of high blood sugar levels.
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