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 D
Explanation
Choice A rationale
Disinfecting the wound bed with alcohol can cause tissue damage and delay healing. The appropriate action is to clean the wound with a saline solution.
Choice B rationale
Preparing sterile dressing supplies 30 minutes before the procedure can compromise sterility. Supplies should be prepared immediately before use.
Choice C rationale
Sterile gloves are worn during the dressing change procedure, not for removing the old dressing. Clean gloves are appropriate for removing the old dressing.
Choice D rationale
Offering the client pain medication before the procedure can help manage pain and discomfort during the dressing change.
Correct Answer is C
Explanation
Choice A rationale
Discussing changes in family roles is important but is not the immediate priority upon admission. This can be addressed once the client's immediate needs are met.
Choice B rationale
Encouraging verbalization of feelings is crucial for mental health support but is not the most urgent action during admission.
Choice C rationale
Determining the client's ability to see the buttons on the call light ensures their immediate safety and ability to call for help, making it the priority.
Choice D rationale
Assisting with locating a community support group is essential for long-term support but is not the first priority upon admission. .
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