"Some mild swelling of my stoma may be seen for 2 to 3 weeks." (Correct Answer)
Some mild swelling of the stoma is expected. The client should report an increase in swelling and change in color from pink to a different color.
"I should drink no more than 1,500 mL of fluid a day now."
The client should not restrict fluids. Increased fluids will decrease the risk of constipation.
"Eating yogurt will decrease odor from the colostomy." (Correct Answer)
Less odor is produced if buttermilk and yogurt are consumed. There is an increased risk of odor if broccoli or garlic is consumed.
"The pouch should be emptied when it is 1/2 to 3/4 full."
The bag should be emptied when it is 1/3 full to decrease the risk of leakage.
"The opening in the pouch for the stoma may need to be adjusted over time." (Correct Answer)
The stoma may decrease in size as healing occurs.
Decision Tree:
This walk-through provides test-taking strategies to determine the correct answer for the different types of questions you will encounter on the NCLEX-RN exam. These strategies are based on the Kaplan Decision Tree (DT) algorithm, a technique that provides a process to determine the correct answer for NCLEX-style questions.
This is a Select All That Apply Question.
This type of question may also be referred to as multiple-select, multiple-response, or SATA. Multiple-select questions have 5 or 6 answer options. At least one option, or as many as all of the options, will be correct. Use these steps, based on the Kaplan Decision Tree, to determine the correct answer.
STEP 1: Can you identify the topic of the question?
STEPS 2-4: These steps are not relevant to this type of question because you do not need to use the rules for Select All That Apply questions. Move to Step 5.
STEP 5: What is the outcome of each answer choice?
Evaluate the outcome(s)
- "Some mild swelling of my stoma may be seen for 2 to 3 weeks." Tissue swelling is expected after surgery.
- "I should drink no more than 1,500 mL of fluid a day now." Restricting fluids may lead to constipation. Only clients in renal failure, heart failure, or SIADH should restrict fluids. Eliminate.
- "Eating yogurt will decrease odor from the colostomy." Eating yogurt does help decrease odor due to the presence of probiotics.
- "The pouch should be emptied when it is 1/2 to 3/4 full." The pouch should be emptied when 1/3 full to prevent accidental leakage. Eliminate.
- "The opening in the pouch for the stoma may need to be adjusted over time." The stoma will gradually decrease in size over several weeks.
Select the best choice:
Are #1, 3, 5 the correct answers? Yes, these are correct statements regarding a new colostomy.
Do #1, 3, 5 make sense? Yes, the client will receive the appropriate education regarding the new colostomy.
