The nurse is completing discharge teaching with a patient following an ileostomy. Which statement by the patient indicates the need for more teaching concerning the ileostomy?
"I can still participate in physical activities and exercise with an ileostomy."
"I should empty the pouch when it is about two-thirds full."
"I should apply adhesive remover to the skin around the stoma when changing the pouch."
"I can eat all my favorite foods now that I have an ileostomy."
The Correct Answer is D
A. This is an appropriate statement. Most patients with an ileostomy can resume physical activities and exercise, though they should be mindful of their stoma and pouch during activities.
B. This is a correct statement. The pouch should be emptied when it is about one-third to one-half full to prevent it from becoming too heavy or causing skin irritation.
C. This is also correct. Adhesive remover can be used to gently remove the pouch and adhesive, preventing irritation to the skin around the stoma.
D. This statement indicates a need for more teaching. While many foods can be eaten after an ileostomy, some foods may cause blockages or discomfort (e.g., nuts, seeds, and high-fiber vegetables). Patients need to be educated on dietary modifications and precautions post-ileostomy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A decrease in the white blood cell count toward normal levels indicates that the infection is responding to antibiotic treatment. A WBC count of 6000/μL is within the normal range for adults (usually 4,000–11,000/μL), which suggests that the body is no longer fighting a significant infection.
B. Bronchial breath sounds heard at the right base indicate consolidation, a sign of ongoing pneumonia or unresolved infection. This would suggest that the infection is not yet controlled, rather than an improvement.
C. Increased tactile fremitus indicates consolidation, which is commonly seen in pneumonia. It suggests that the infection is still present and has not resolved with treatment.
D. Green mucus can indicate the presence of purulent sputum and ongoing infection. Although the color of the mucus may change during the course of pneumonia, the presence of green mucus does not confirm that the infection is resolving, especially after three days of antibiotics.
Correct Answer is B
Explanation
A. While assessing sputum is important to determine its color, consistency, and amount, it is not the priority before performing percussion, vibration, and postural drainage. The nurse should first assess the patient's overall respiratory status.
B. Assessing pulse and respirations is the first step in ensuring the patient's baseline respiratory status is stable before performing respiratory therapies. This allows the nurse to detect any signs of distress or abnormal respiratory patterns, which could indicate the need for further intervention before the procedure.
C. Auscultating lung fields is important for evaluating the effectiveness of the percussion and drainage procedure, but the initial assessment should include vital signs, such as pulse and respirations, to ensure the patient is stable.
D. Instructing the patient to slowly exhale with pursed lips is a helpful technique for managing respiratory distress, but it is not the first priority before conducting percussion or postural drainage. The nurse should first assess vital signs.
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