A nurse is reinforcing teaching with a client who is scheduled for a sigmoid colon resection with colostomy. Which of the following statements by the client indicates a need for further teaching?
“Because most of my colon is still intact and functioning, my stool will be formed.”
“My stoma will appear large at first, but it will shrink over time.”
“My colostomy will begin to function 2 to 6 days after surgery.”
“My diet will have to change to a soft diet after surgery.”
The Correct Answer is D
Choice A reason: This is a correct statement, because the stool consistency depends on the location of the colostomy. A sigmoid colostomy is located in the lower part of the colon, where most of the water is absorbed, so the stool will be formed.
Choice B reason: This is a correct statement, because the stoma size will decrease as the swelling subsides and the wound heals. The stoma will reach its final size in about 6 to 8 weeks after surgery.
Choice C reason: This is a correct statement, because the colostomy function will resume gradually after surgery, depending on the bowel motility and the presence of gas or stool. The colostomy will usually start to function 2 to 6 days after surgery.
Choice D reason: This is an incorrect statement, because the diet does not have to change to a soft diet after surgery. The client can resume a normal diet as tolerated, unless there are specific dietary restrictions or recommendations from the provider. A soft diet may be recommended only for the first few days after surgery, to avoid bowel obstruction or irritation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is an important action, but not the first one. The nurse should obtain sample menus from the dietitian to give to the client after assessing the client's food preferences, needs, and goals. The sample menus should be individualized and tailored to the client's lifestyle, culture, and preferences.
Choice B reason: This is the first action, because the nurse should ask the client to identify the types of foods she prefers before providing any dietary teaching. This can help the nurse to determine the client's current eating habits, knowledge, and readiness to learn. It can also help the nurse to establish rapport and trust with the client, and to involve the client in the decision-making process.
Choice C reason: This is an important action, but not the first one. The nurse should identify the recommended range for the client's blood glucose level after assessing the client's food preferences, needs, and goals. The recommended range for the blood glucose level depends on the type, dose, and timing of the medication, the frequency and intensity of the exercise, and the carbohydrate intake of the client.
Choice D reason: This is an important action, but not the first one. The nurse should discuss long-term complications that can result from nonadherence to the dietary plan after assessing the client's food preferences, needs, and goals. The long-term complications of diabetes mellitus include cardiovascular disease, kidney disease, nerve damage, eye damage, and foot problems. The nurse should explain the benefits of following the dietary plan and the risks of not following it.
Correct Answer is B
Explanation
Choice A reason: This is a correct statement, because using a soft toothbrush or foam swab for oral care can help prevent trauma and irritation to the mucous membranes of the mouth, which are inflamed and ulcerated due to stomatitis. The client should brush the teeth gently and avoid using dental floss.
Choice B reason: This is an incorrect statement, because using an alcohol-based mouthwash can cause burning, drying, and further damage to the mucous membranes of the mouth, which are already compromised by stomatitis. The client should avoid using any mouthwash that contains alcohol, menthol, or other harsh ingredients.
Choice C reason: This is a correct statement, because using a straw when drinking liquids can help reduce the contact and friction of the fluids with the mouth sores, which can cause pain and discomfort. The client should drink plenty of fluids to prevent dehydration and maintain hydration.
Choice D reason: This is a correct statement, because rinsing the mouth frequently with a hydrogen peroxide solution can help cleanse and disinfect the mouth, and promote healing of the mouth sores. The client should dilute the hydrogen peroxide with water and rinse the mouth at least four times a day, or as prescribed by the provider.
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