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: The width of the BP cuff should actually be 40% of the client's upper arm circumference, not 50%. Using a cuff that's too large can result in a falsely low reading, while a cuff that's too small can cause a falsely high reading.
B: It is important to recheck the BP in the other arm to compare readings. Differences in blood pressure between arms can indicate vascular issues and provide valuable diagnostic information. Consistency in readings is crucial for accurate diagnosis and treatment.
C: While it may be necessary to monitor the client's BP over time, immediately requesting another nurse to check the BP does not address the immediate concern of the accuracy of the initial reading.
D: Repositioning the client supine may be appropriate if orthostatic hypotension is suspected, but it is not the first action to take. The initial step should be to confirm the accuracy of the reading by checking the other arm.

A. Turn the client onto their side. B. Help the client lie on the floor. C. Loosen the client's clothing. D. Move items in the room away from the client.

Correct Answer is B

Explanation

A. Turning the client onto their side helps prevent aspiration and ensures a clear airway but since the client is seated on a chair, they run the risk of getting a fall hence lying them down is the priority.
B. If a client has a seizure when seated, it is best to ensure their safety by lying them on the floor and moving any objects that can cuase injury.
C. Loosening clothing is important but not the priority over ensuring a clear airway.
D. Moving items away from the client is important to prevent injury, but ensuring airway safety comes first.

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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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