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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Eyewear should be removed after the gown as part of the sequence to prevent exposure to potential contaminants.
B. The mask should be removed after the gown to prevent contamination of the nurse's face.
C. The nurse should follow the sequence of doffing personal protective equipment (PPE) recommended by the Centers for Disease Control and Prevention (CDC) to prevent contamination. The sequence is: gloves, gown, eyewear, and mask. Gloves are the most contaminated piece of PPE and should be removed first by grasping the outside of one glove at the wrist and peeling it off, then holding it in the gloved hand and sliding the fingers of the ungloved hand under the remaining glove at the wrist and peeling it off over the first glove. The nurse should then discard both gloves in a waste container.
D. The gown is removed after the gloves when leaving the room to prevent carrying any potential contaminants outside the patient's room and to maintain infection control measures.
Correct Answer is C
Explanation
A. Involving the supervisor for a temporary password might not be necessary when other options for password recovery are available.
B. Asking another nurse to document on behalf of the newly licensed nurse might lead to issues related to accountability and accuracy.
C. Providing contact information for password recovery assistance is the most appropriate action.
D. Sharing passwords compromises security and violates policies and should be avoided.
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