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.
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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Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale
The presence of a grab bar in the bathroom is actually a safety measure that can help prevent falls. It provides support for the patient when they are getting up or moving around, reducing the risk of a fall.
Choice B rationale
An electrical cord lying across a walkway is a tripping hazard and would increase the patient’s risk of falling. It is important to keep walkways clear of clutter and potential obstacles to prevent falls.
Choice C rationale
Macular degeneration can affect the patient’s vision, making it difficult for them to see obstacles or changes in the walking surface. This can increase their risk of falling.
Choice D rationale
Throw rugs in the kitchen can easily slip or bunch up, creating a tripping hazard. They should be secured with non-slip backing or removed to reduce the risk of falls.
Choice E rationale
While a cane can provide support and improve balance, it also indicates that the patient has mobility issues, which increases their risk of falling. It is important that the patient uses the cane correctly and that it is the right height for them.
Correct Answer is A
Explanation
Choice A rationale
Donning sterile gloves before inserting the indwelling urinary catheter is a critical step to prevent infection. The urinary tract is normally sterile, and using sterile gloves helps maintain this sterility during the procedure.
Choice B rationale
Applying an oil-based lubricant to the indwelling urinary catheter is not recommended. Oil- based lubricants can damage latex catheters and increase the risk of infection. A water-soluble lubricant is typically used.
Choice C rationale
Using one cotton swab to clean the client’s genitalia is not sufficient. Proper cleaning and disinfection of the area are crucial to prevent introducing bacteria into the urinary tract during catheter insertion.
Choice D rationale
Testing the balloon on the indwelling urinary catheter before insertion is not typically done. The balloon is usually inflated with sterile water once the catheter is in place to ensure that it remains in the bladder.
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