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 D

Explanation

A. Dismissing the client's concerns by stating everything will be fine doesn’t acknowledge their anxiety or offer reassurance.
B. While validating common feelings of fear might be helpful, it doesn't directly address the client's concerns or provide coping strategies.
C. Asking why the client feels scared might come across as confrontational or probing, possibly escalating their anxiety.
D. Offering to discuss what the client can expect during their stay provides reassurance, helps manage expectations, and gives the client a sense of control and understanding about their situation.

A. "You should discuss these feelings with your provider." B. "Have you thought about harming yourself?" C. "Why did you stop taking your medication?" D. "Tell me more about your partner."

Correct Answer is B

Explanation

A. Advising to discuss with the provider doesn't address the immediate concern of potential harm.
B. Asking about thoughts of self-harm assesses the client's immediate safety.
C. Inquiring about medication discontinuation is important but not as urgent as addressing suicidal ideation.
D. While understanding the relationship is important, it's not the priority when a client expresses suicidal thoughts.

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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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Explanation

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