A nurse is caring for a client who has a new colostomy. Which of the following statements should the nurse include in educating the client regarding colostomy care?

"Cut the opening on the skin barrier wafer to customize fit over the stoma.".

"Empty the bag when it is three-fourths full of stool.".

"The color of the stoma should be slightly purple.".

"Cleanse the peristomal skin with moisturizing soap and water.".

Answer and Explanation

The Correct Answer is A

Choice A rationale:
Properly cutting the opening on the skin barrier wafer to fit over the stoma is crucial to prevent any irritation or damage to the surrounding skin. A well-fitted wafer creates a seal around the stoma, reducing the risk of stool coming into contact with the skin, which can cause excoriation.
Choice B rationale:
Emptying the bag when it is three-fourths full of stool is unrelated to the education on colostomy care. This information was provided in the previous question () and is not relevant to colostomy care education.
Choice C rationale:
The color of the stoma should not be slightly purple. A healthy stoma should be pink or red, indicating a good blood supply. A purple or dark-colored stoma could indicate inadequate blood flow, which is a concern and requires immediate medical attention.
Choice D rationale:
Cleansing the peristomal skin with moisturizing soap and water is not the recommended approach. The nurse should use plain water or mild, non-moisturizing soap to clean the peristomal skin, as moisturizing soap may leave a residue that affects the adhesion of the skin barrier wafer.

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Correct Answer is D

Explanation

Choice A rationale:
Fruity-smelling breath is associated with diabetic ketoacidosis (DKA), which is not the expected manifestation of chronic kidney disease (CKD). DKA occurs in uncontrolled diabetes and is not the priority for this client.
Choice B rationale:
Painful urination is not a typical clinical manifestation of chronic kidney disease. It is more commonly associated with urinary tract infections or other urological issues.
Choice C rationale:
Hypotension may occur in end-stage kidney disease, but it is not specific to chronic kidney disease and is not a priority in this scenario.
Choice D rationale:
Lethargy is a common clinical manifestation of chronic kidney disease due to the accumulation of waste products in the blood, leading to uremia. It is a priority as it indicates the progression of the disease and the need for close monitoring and intervention.

A. Assess the need for oral suction every 4 hr. B. Check the ventilator settings every 12 hr. C. Keep the head of the client's bed elevated at 30°. D. Perform oral hygiene using an alcohol-based oral rinse.

Correct Answer is C

Explanation

Choice A rationale:
Assessing the need for oral suction every 4 hours is essential in maintaining airway patency and preventing complications associated with excessive secretions. This is an appropriate action and does not require clarification.
Choice B rationale:
Checking the ventilator settings every 12 hours is necessary to ensure that the mechanical ventilation is providing adequate support for the client's respiratory needs. This prescription is appropriate and does not need clarification.
Choice C rationale:
Keeping the head of the client's bed elevated at 30° is important in preventing aspiration and ventilator-associated pneumonia. This position helps promote optimal lung expansion and improves oxygenation in ventilated clients.
Choice D rationale:
Performing oral hygiene using an alcohol-based oral rinse is not recommended for clients receiving mechanical ventilation. Alcohol-based products can be harmful if aspirated and may disrupt the normal oral flora, leading to complications. The nurse should use a non-alcohol-based oral rinse or foam swabs instead.

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A nurse is caring for a client who has a new colostomy. Which of the following statements should the nurse include in educating the client regarding colostomy care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has chronic kidney disease. The nurse should expect the client to have which of the following clinical manifestations?

Correct Answer is D

Explanation

A nurse is planning care for a client who is receiving mechanical ventilation. Which of the following actions should the nurse include in the plan of care?

Correct Answer is C

Explanation

A nurse is assessing a client for manifestations of mild Alzheimer's disease. Which of the following findings should the nurse expect as an early indication of the disease?

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