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 C

Explanation

A. Starting a blood transfusion without obtaining consent is a violation but may fall more under the category of battery than negligence.
B. Preventing a client from leaving the facility might relate more to issues of false imprisonment or breach of autonomy rather than negligence.
C. Administering medication without properly identifying the client can be considered negligence as it breaches the standard duty of care.
D. Discussing client care in a public area with visitors present might breach confidentiality but might not be categorized as negligence unless sensitive or protected information was disclosed.

A. Client educator B. Client advocate C. Client care provider D. Case manager

Correct Answer is C

Explanation

A. Client educator: Involves imparting knowledge or information to the client or others, which isn't the primary role of the nurse manager in this scenario.
B. Client advocate: Represents and supports the client's rights and needs.
C. Client care provider: The nurse manager is ensuring proper care provision by overseeing the procedure directly.
D. Case manager: Coordinates care and resources for the client's overall plan but isn't directly involved in overseeing a specific procedure.

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

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Naxlex Comprehensive Predictor Exams

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