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 A
Explanation
Choice A rationale
Clonidine can cause dry mouth, which is a common side effect of the medication.
Choice B rationale
Hypopigmentation under the patch is not a common side effect of clonidine and does not need to be monitored.
Choice C rationale
Diarrhea is not a common adverse effect of clonidine. It is not typically associated with the medication.
Choice D rationale
Clonidine is not known to cause weight loss. Monitoring for this is unnecessary. .
Correct Answer is A
Explanation
Choice A rationale
Weighing the client before and after peritoneal dialysis helps assess fluid balance and ensure that the correct amount of fluid is removed during treatment. Monitoring weight changes is critical for evaluating the effectiveness of the dialysis.
Choice B rationale
Clean gloves are not sufficient for handling dialysate bags; sterile technique is required to prevent infection. Peritoneal dialysis involves a sterile procedure to reduce the risk of peritonitis.
Choice C rationale
The dialysate should be warmed to body temperature before infusion to prevent discomfort and vasoconstriction. Chilling the dialysate can cause abdominal cramping and reduce the effectiveness of the treatment.
Choice D rationale
Monitoring for diarrhea is not a standard part of peritoneal dialysis care. Peritonitis, not diarrhea, is a common complication of peritoneal dialysis, so monitoring for signs of infection is crucial.
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