Nokea
The client diagnosed with ulcerative colitis has an ileostomy. Which statement indicates the client needs more teaching concerning the ileostomy?
- A. My stoma should be pink and moist.
- B. I will irrigate my ileostomy every morning.
- C. If I get a red, bumpy, itchy rash I will call my HCP.
- D. I will change my pouch if it starts leaking.
Correct Answer: B
Rationale: Ileostomies typically do not require routine irrigation, as the output is liquid and continuous, unlike colostomies. The other statements reflect correct understanding of stoma care and management.
You may also like to solve these questions
The client with a history of peptic ulcer disease is admitted into the intensive care department with frank gastric bleeding. Which priority intervention should the nurse implement?
- A. Maintain a strict record of intake and output.
- B. Insert a nasogastric (NG) tube and begin saline lavage.
- C. Assist the client with keeping a detailed calorie count.
- D. Provide a quiet environment to promote rest.
Correct Answer: B
Rationale: Inserting an NG tube with saline lavage helps remove blood, assess bleeding severity, and stabilize the client with frank gastric bleeding. Intake/output monitoring, calorie counts, and rest are secondary to controlling active hemorrhage.
The client is diagnosed with esophageal diverticula. Which lifestyle modification should be taught by the nurse?
- A. Raise the foot of the bed to 45 degrees to increase peristalsis.
- B. Eat the evening meal at least two (2) hours prior to bed.
- C. Eat a low-fat, low-cholesterol, high-fiber diet.
- D. Wear an abdominal binder to strengthen the abdominal muscles.
Correct Answer: B
Rationale: Eating at least two hours before bed prevents food pooling in the diverticula, reducing regurgitation risk. Raising the bed foot, specific diets, and binders are not standard.
The client who has had an abdominal perineal resection is being discharged. Which discharge information should the nurse teach?
- A. The stoma should be a white, blue, or purple color.
- B. Limit ambulation to prevent the pouch from coming off.
- C. Take pain medication when the pain level is at an '8.'
- D. Empty the pouch when it is one-third to one-half full.
Correct Answer: D
Rationale: Emptying the pouch when one-third to one-half full prevents leaks and skin irritation. A healthy stoma is pink/moist, ambulation is encouraged, and pain medication should be taken before pain becomes severe.
The nurse is developing a plan of care for the client with cirrhosis. Which intervention should be included in the client’s plan of care?
- A. Monitor the client’s blood sugar level.
- B. Place the client on NPO status.
- C. Administer antibiotics every 6 hours.
- D. Encourage ambulation every 4 hours.
Correct Answer: A
Rationale: A. The nurse should prepare to monitor the client’s blood sugar level. The client with cirrhosis may develop insulin resistance. Impaired glucose tolerance is common with cirrhosis, and about 20% to 40% of clients also have diabetes. Hypoglycemia may occur during fasting because of decreased hepatic glycogen reserves and decreased gluconeogenesis. B. The client with cirrhosis would not be NPO but should receive a high-protein diet unless hepatic encephalopathy is present. C. Antibiotics are not part of the treatment plan of cirrhosis because it is not caused by microorganisms. D. The client with cirrhosis requires rest; thus, ambulation should not be encouraged every 4 hours.
The client tells the nurse about being diagnosed with a 2-cm cancerous tumor in the liver. The client wants to know about the treatment. Which statement should be the basis for the nurse’s response?
- A. The use of chemotherapy is the first-line treatment for liver cancer.
- B. Liver transplantation is not an option for clients with liver cancer.
- C. Radiofrequency ablation can be successful in treating tumors of this size.
- D. A tumor of this size can only be removed through an open surgical approach.
Correct Answer: C
Rationale: A. Chemotherapy is only used for clients who are not likely to benefit from other therapies. B. Liver transplantation is used when the tumor is large or localized. C. Radiofrequency ablation is a treatment technique that uses high-frequency alternating electrical current to heat tissue cells and destroy them. It can be successfully used to treat tumors less than 5 cm in size because these tumors tend to be slow growing and encapsulated. D. Surgical resection of the tumor is used when the tumor is large or localized.