Which of the following client statements would cause the nurse to further question the client?

I have been having a little diarrhea when I take my antibiotics

My colostomy output has changed to green after lunch today

I have been having a strong-smelling liquid stool for a few days

My stool has been thick and black when I take my ferrous sulfate

Answer and Explanation

The Correct Answer is C

Choice A reason: Antibiotic-associated diarrhea is common due to gut flora disruption, often benign or linked to Clostridium difficile. This statement aligns with expected side effects, requiring monitoring but not immediate further questioning compared to persistent symptoms.

Choice B reason: Green colostomy output can result from dietary changes (e.g., green vegetables) or medications. This is a normal variation and does not warrant urgent questioning unless accompanied by systemic symptoms like fever or pain.

Choice C reason: Strong-smelling liquid stool for several days suggests potential infection, malabsorption, or inflammatory conditions (e.g., C. difficile, colitis). Persistent symptoms warrant further questioning to assess duration, associated symptoms, and risk factors for serious pathology.

Choice D reason: Black, thick stool is a known side effect of ferrous sulfate due to iron oxidation in the gut. This is benign and expected, not requiring further questioning unless other symptoms like bleeding are present.

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Correct Answer is D

Explanation

Choice A reason: Advancing the catheter 2.5-5 cm after urine flow is incorrect, as this risks advancing too far, potentially injuring the bladder or urethra. The catheter should be inserted until urine flows, then slightly further to ensure bladder placement.

Choice B reason: Contracting pelvic muscles during catheterization is not advised, as it may increase resistance or cause discomfort. Patients should relax to facilitate smooth catheter insertion and minimize trauma to the urethra.

Choice C reason: Inflating a balloon is specific to indwelling (Foley) catheters, not intermittent ones, which lack balloons. This instruction is irrelevant and could confuse the patient, as intermittent catheters are removed after bladder emptying.

Choice D reason: Lubricating the catheter tip with water or water-soluble lubricant reduces friction, easing insertion and minimizing urethral trauma. This is a critical step in self-catheterization to ensure safety and comfort, making it an essential instruction.

A. Thoroughly cleansing the skin around the stoma with soap and water to remove excess stool and adhesive. B. Measuring the correct size for the barrier device while leaving a 1/2-inch space around the stoma. C. Emptying the pouch if it is more than one-third to one-half full. D. Changing the skin barrier portion of the ostomy pouch daily.

Correct Answer is C

Explanation

Choice A reason: Using soap and water to cleanse the stoma site risks skin irritation, as soap can disrupt the skin’s natural barrier, leading to dermatitis or poor pouch adhesion. Gentle cleansing with water or specialized products is preferred to maintain peristomal skin integrity and prevent complications.

Choice B reason: Leaving a 1/2-inch space around the stoma is excessive. The barrier should fit closely (1/16 to 1/8 inch) to protect peristomal skin from effluent, which can cause irritation or breakdown. A larger gap risks skin damage, compromising pouch adherence and patient comfort.

Choice C reason: Emptying the pouch when one-third to one-half full is appropriate. This prevents leakage, reduces pouch weight, and maintains skin integrity by minimizing effluent contact. Regular emptying supports patient comfort and prevents complications like skin irritation or pouch detachment, critical for ileostomy care.

Choice D reason: Changing the skin barrier daily is unnecessary unless leakage or skin issues occur. Barriers typically last 3-7 days, depending on output and skin condition. Daily changes risk skin trauma from frequent adhesive removal, increasing irritation and compromising peristomal skin health.

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Which of the following client statements would cause the nurse to further question the client?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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