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. 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.

A. Elevate full-length side rails on both sides of the client's bed. B. Place the bedside table 0.9 m (3 feet) away from the bed. C. Provide the client with a night light. D. Keep the client's room temperature at 18° C (64.4" F).

Correct Answer is C

Explanation

A. Elevating full-length side rails on both sides of the client's bed is not recommended, as it can increase the risk of injury if the client tries to climb over them or gets trapped between them.

B. Placing the bedside table 0.9 m away is unrelated to fall prevention.
C. A night light can help the client see better in the dark and avoid tripping or falling over objects.
D. Maintaining the room temperature is important for comfort but doesn't directly prevent falls.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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