A nurse is providing teaching about ileostomy care to a client. Which of the following statements by the client indicates a need for further teaching?
“I will empty my pouch when it becomes 1/3 full.”
“I will be careful to take enteric-coated medications.”
“I will change my entire pouch system at least weekly.”
“I will use caution when eating high-fiber foods.”
The Correct Answer is B
Rationale:
A. Emptying the pouch when it becomes 1/3 full is appropriate and helps prevent leakage and odor. This statement shows understanding of proper pouch management.
B. Enteric-coated medications can be problematic for clients with an ileostomy as they may not dissolve properly in the digestive system, potentially leading to decreased absorption. The client should be aware that these medications may not be suitable for their condition.
C. Changing the entire pouch system at least weekly is a common recommendation to maintain hygiene and skin integrity. This indicates the client understands the need for regular pouch maintenance.
D. Caution when eating high-fiber foods is important, as these foods can cause blockages in the ileostomy. This statement reflects the client’s awareness of dietary considerations for managing their ileostomy.
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Correct Answer is D
Explanation
Rationale:
A. "Kennet" is not a recognized food or beverage and is not known to cause bladder irritation. The question might include this as a distractor.
B. "Frestat" is also not a known food or beverage associated with bladder irritation and does not play a role in urinary incontinence management.
C. Dairy products generally do not cause bladder irritation. Although some individuals may experience sensitivity to dairy, it is not commonly associated with bladder irritation or incontinence.
D. Caffeinated beverages are known bladder irritants. Caffeine can increase urine production and stimulate bladder activity, leading to increased urgency and frequency, which can exacerbate urinary incontinence.
Correct Answer is ["A","C","D","E"]
Explanation
Rationale:
A. A client with right-sided heart failure and 4+ edema is at risk for pressure ulcers due to fluid accumulation, which can impair circulation and increase the likelihood of skin breakdown.
B. A client who is ambulatory is at a low risk for pressure ulcers because frequent movement reduces the risk of prolonged pressure on any one area.
C. A client with type 1 diabetes mellitus and hyperglycemia is at risk for pressure ulcers because high blood glucose levels can impair wound healing and affect skin integrity.
D. A client with protein-calorie malnutrition is at a significant risk for pressure ulcers due to inadequate nutrition, which weakens the skin and impairs the body’s ability to repair tissue damage.
E. A client with postoperative delirium may have decreased mobility and cognitive awareness, making it harder for them to reposition themselves, thereby increasing their risk of pressure ulcers.