A nurse is teaching a client who is preoperative for an ileostomy. Which of the following statements should the nurse include?

You will have a stoma placed in your right lower abdomen.

The end of the stoma will be painful after this procedure.

You should expect your stoma to be a purple color.

You will have solid stool pass through your stoma.

Answer and Explanation

The Correct Answer is AANDD

Choice A rationale

An ileostomy involves creating a stoma, or opening, in the abdominal wall. The location of the stoma is typically in the right lower abdomen.

Choice B rationale

The end of the stoma should not be painful after the procedure. If the patient experiences pain, it could indicate a complication and should be reported to the healthcare provider.

Choice C rationale

The patient should not expect the stoma to be a purple color. A healthy stoma should be red or pink. A purple stoma could indicate a lack of blood flow, which is a serious issue that needs immediate medical attention.

Choice D rationale

After an ileostomy, the patient will have liquid or semi-liquid stool pass through the stoma. This is because the large intestine, which normally absorbs water and forms solid stool, is bypassed or removed in the procedure.

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Correct Answer is C

Explanation

Choice A rationale

Full-thickness skin loss with visible bone is characteristic of a stage 4 pressure injury, not a stage 1 pressure injury.

Choice B rationale

Full-thickness skin loss with visible adipose tissue is characteristic of a stage 3 pressure injury, not a stage 1 pressure injury.

Choice C rationale

In a stage 1 pressure injury, the skin remains intact with localized erythema. The area may be painful, firm, soft, warmer, or cooler compared to adjacent tissue.

Choice D rationale

Partial-thickness skin loss with red tissue in the wound bed is characteristic of a stage 2 pressure injury, not a stage 1 pressure injury.

Correct Answer is ["24"]

Explanation

Step 1 is: To find out how many mL/hr the IV pump should be set to deliver, we need to set up a proportion with the prescribed units of heparin on one side and the available units of heparin on the other side. So, the calculation is: (1,200 units/hr ÷ 25,000 units) × 500 mL = 24 mL/hr.

Therefore, the IV pump should be set to deliver 24 mL/hr.

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A nurse is teaching a client who is preoperative for an ileostomy. Which of the following statements should the nurse include?

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Naxlex Comprehensive Predictor Exams

A nurse is evaluating a patient who has a stage 1 pressure injury. What findings should the nurse anticipate?

Correct Answer is C

Explanation

Correct Answer is ["24"]

Explanation

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