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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While this patient is scheduled for a physical therapy session, it is not an urgent concern that would require immediate attention.
B. A routine follow-up appointment for a non-urgent condition can be managed at a later time and does not take priority over more acute concerns.
C. A patient with altered mental status and confusion should be assessed first. This could indicate a serious underlying issue such as infection, hypoxia, or a neurological condition. Altered mental status in any patient warrants immediate attention to prevent further complications.
D. Although the patient with pleuritis is in pain, moderate pleuritis is typically not an urgent condition, and pain management can be provided after more pressing concerns are addressed.
Correct Answer is A
Explanation
A. A fever following an upper gastrointestinal endoscopy can be a sign of a serious complication, such as perforation, which could cause peritonitis. The nurse should promptly assess the client for other signs of perforation, such as abdominal pain, rigidity, or changes in vital signs. This is a critical and potentially life-threatening situation that requires immediate attention.
B. While it is important to ensure accurate temperature readings, a fever of 101.8°F in a post-procedural patient is concerning and warrants further investigation rather than just retaking the temperature. It may indicate a complication such as infection or perforation.
C. Administering acetaminophen to reduce the fever is not the first step. The nurse should prioritize investigating the underlying cause of the fever, as it could indicate a more serious complication like perforation, which would not be resolved by medication alone.
D. Bathing the client with tap water is not appropriate. A fever after a procedure should be investigated thoroughly rather than treated symptomatically without understanding the cause. The nurse should focus on assessing for complications first.
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