A nurse is caring for a client who has a colostomy. Which of the following actions should the nurse take?

Rub the peristomal skin dry after cleaning.

Change the pouch once every 24 hr.

Ensure the pouch is 0.32 cm (1/8 in) larger than the stoma.

Apply the pouch while the skin barrier is still damp.

Answer and Explanation

The Correct Answer is C

A.   Rather than rubbing dry, patting the peristomal skin dry after cleaning is recommended.
B.   The frequency of changing the pouch depends on various factors, not a fixed 24-hour schedule.
C.   Ensuring the pouch is slightly larger than the stoma prevents irritation and damage.
D.   Applying the pouch when the skin barrier is dry ensures better adhesion.

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Correct Answer is B

Explanation

A. Massaging bony prominences can actually increase the risk of pressure injury by causing friction and shearing forces on the skin.
B. Elevating the heels reduces the pressure on the skin and improves blood circulation.
C. Raising the head of the bed to a 60° angle doesn't directly address pressure injury prevention and might even increase pressure on certain areas.
D. Repositioning the client every 4 hours is not frequent enough to prevent pressure injuries.

A. Elevate full-length side rails on both sides of the client's bed. B. Place the bedside table 0.9 m (3 feet) away from the bed. C. Provide the client with a night light. D. Keep the client's room temperature at 18° C (64.4" F).

Correct Answer is C

Explanation

A. Elevating full-length side rails on both sides of the client's bed is not recommended, as it can increase the risk of injury if the client tries to climb over them or gets trapped between them.

B. Placing the bedside table 0.9 m away is unrelated to fall prevention.
C. A night light can help the client see better in the dark and avoid tripping or falling over objects.
D. Maintaining the room temperature is important for comfort but doesn't directly prevent falls.

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A nurse is caring for a client who has a colostomy. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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