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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Two-point alternating gait involves partial weight-bearing on both legs and wouldn’t suit a client who can bear weight on only one leg.
B. Four-point alternating gait involves walking by moving one crutch followed by the opposite leg and is not suitable for a person who can bear weight on just one leg.
C. Swing-through gait involves swinging both legs forward between the crutches, typically used for individuals who have little or no weight-bearing ability.
D. Three-point gait involves bearing weight on one leg while using crutches and moving the other leg forward, the most appropriate gait for someone who can bear weight on one leg.
Correct Answer is B
Explanation
A. Logrolling is used to turn clients with spinal injuries, not typically for general immobile clients, and performing it every 4 hours might not be necessary or appropriate.
B. Using trochanter rolls beside the client's legs helps maintain proper alignment and prevents external rotation, which can lead to hip joint complications.
C. Placing the client's arms at their side when turning might restrict movement and not aid in proper alignment or comfort.
D. Crossing the client's ankles when lying supine might cause pressure injuries or discomfort due to increased pressure on the ankles.
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