A nurse is teaching a client who has an ileostomy about the care of their stoma site. Which of the following statements made by the client indicates the teaching was effective?

"I should clean my stoma with moisturizing soaр."

"I should expect my stoma to be blistered."

"I should cut my pouch opening 1/8 inch larger than my stoma."

"I should change my stoma pouch 30 minutes after meals."

Answer and Explanation

The Correct Answer is C

Rationale:
A. "I should clean my stoma with moisturizing soap.": Moisturizing soaps can leave a residue that interferes with the adhesive seal of the ostomy pouch. The stoma and surrounding skin should be cleaned gently with mild, non-moisturizing soap and water to maintain skin integrity and pouch adhesion.

B. "I should expect my stoma to be blistered.": A healthy stoma should appear pink to red and moist. Blistering indicates trauma, irritation, or infection, which requires assessment and intervention, so this expectation is incorrect.

C. "I should cut my pouch opening 1/8 inch larger than my stoma.": Proper pouch sizing ensures a secure fit around the stoma while protecting the surrounding skin from effluent. Cutting the opening slightly larger than the stoma prevents pressure and irritation.

D. "I should change my stoma pouch 30 minutes after meals.": Ostomy pouch changes should be scheduled when effluent is minimal, typically every 3–7 days or when the pouch is leaking. Timing changes specifically after meals is unnecessary.

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Correct Answer is B

Explanation

Rationale:
A. Wrap their arms under the client's axilla to transfer the client: Manually lifting a heavy, dependent client by placing arms under the axilla is unsafe and can cause serious musculoskeletal injuries to both the nurse and the client.

B. Use a powered lift to transfer the client: A powered mechanical lift is the safest and most appropriate method for transferring a 136-kg (300-lb) client who cannot assist. It prevents strain on healthcare workers, reduces the risk of falls, and ensures a smooth, controlled transfer from bed to chair.

C. Use a gait belt to transfer the client: A gait belt is used only for clients who can bear some weight and actively assist in the transfer. Since this client is unable to help, using a gait belt would not provide adequate support or safety during the transfer process.

D. Use a sliding board to transfer the client: Sliding boards are designed for clients who have upper body strength and can assist by lifting or shifting themselves during the transfer. In this case, the client’s inability to assist makes a powered lift the only safe and feasible option.

A. Sunken fontanels and dry mucous membranes B. Temperature 38° C (100.4° F) and pulse rate 124/min C. Pale and a 24-hr fluid deficit of 30 mL D. Decreased appetite and irritability

Correct Answer is A

Explanation

Rationale:
A. Sunken fontanels and dry mucous membranes: These findings indicate moderate to severe dehydration, which can quickly become life-threatening in an infant. Prompt notification of the provider is essential to initiate fluid replacement and prevent complications such as hypovolemic shock.

B. Temperature 38° C (100.4° F) and pulse rate 124/min: A low-grade fever and mildly elevated pulse are common in gastroenteritis and typically do not require immediate reporting unless accompanied by other concerning symptoms like poor perfusion or lethargy.

C. Pale and a 24-hr fluid deficit of 30 mL: A fluid deficit of 30 mL over 24 hours is minimal in an infant and not immediately concerning. Monitoring should continue, but urgent reporting is not necessary for this level of deficit.

D. Decreased appetite and irritability: These are expected symptoms of gastroenteritis in infants and can be managed with routine supportive care and monitoring. They are not specific indicators of severe dehydration requiring immediate provider intervention.

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A nurse is teaching a client who has an ileostomy about the care of their stoma site. Which of the following statements made by the client indicates the teaching was effective?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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