A nurse is caring for a patient with an ileostomy. Which action by the nurse is most appropriate?
Thoroughly cleansing the skin around the stoma with soap and water to remove excess stool and adhesive.
Measuring the correct size for the barrier device while leaving a 1/2-inch space around the stoma.
Emptying the pouch if it is more than one-third to one-half full.
Changing the skin barrier portion of the ostomy pouch daily.
The Correct Answer is C
Choice A reason: Using soap and water to cleanse the stoma site risks skin irritation, as soap can disrupt the skin’s natural barrier, leading to dermatitis or poor pouch adhesion. Gentle cleansing with water or specialized products is preferred to maintain peristomal skin integrity and prevent complications.
Choice B reason: Leaving a 1/2-inch space around the stoma is excessive. The barrier should fit closely (1/16 to 1/8 inch) to protect peristomal skin from effluent, which can cause irritation or breakdown. A larger gap risks skin damage, compromising pouch adherence and patient comfort.
Choice C reason: Emptying the pouch when one-third to one-half full is appropriate. This prevents leakage, reduces pouch weight, and maintains skin integrity by minimizing effluent contact. Regular emptying supports patient comfort and prevents complications like skin irritation or pouch detachment, critical for ileostomy care.
Choice D reason: Changing the skin barrier daily is unnecessary unless leakage or skin issues occur. Barriers typically last 3-7 days, depending on output and skin condition. Daily changes risk skin trauma from frequent adhesive removal, increasing irritation and compromising peristomal skin health.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Antibiotic-associated diarrhea is common due to gut flora disruption, often benign or linked to Clostridium difficile. This statement aligns with expected side effects, requiring monitoring but not immediate further questioning compared to persistent symptoms.
Choice B reason: Green colostomy output can result from dietary changes (e.g., green vegetables) or medications. This is a normal variation and does not warrant urgent questioning unless accompanied by systemic symptoms like fever or pain.
Choice C reason: Strong-smelling liquid stool for several days suggests potential infection, malabsorption, or inflammatory conditions (e.g., C. difficile, colitis). Persistent symptoms warrant further questioning to assess duration, associated symptoms, and risk factors for serious pathology.
Choice D reason: Black, thick stool is a known side effect of ferrous sulfate due to iron oxidation in the gut. This is benign and expected, not requiring further questioning unless other symptoms like bleeding are present.
Correct Answer is C
Explanation
Choice A reason: Specific gravity of 1.036 is slightly above the normal range (1.005-1.030), suggesting concentrated urine, possibly from dehydration. While it warrants monitoring, it is not immediately alarming compared to proteinuria, which indicates potential renal pathology.
Choice B reason: Urine output of 80 mL/hr (1920 mL/day) is within normal adult range (800-2000 mL/day). This does not require immediate follow-up, as it reflects adequate renal perfusion and function under normal conditions.
Choice C reason: Protein level of 2 mg/100 mL (20 mg/L) indicates proteinuria, abnormal as normal urine protein is <150 mg/day. This suggests potential glomerular damage, infection, or systemic disease (e.g., diabetes), requiring urgent follow-up to diagnose and manage underlying pathology.
Choice D reason: Urine pH of 6.4 is within the normal range (4.5-8.0), reflecting typical dietary and metabolic influences. It does not indicate an abnormality requiring follow-up, as it aligns with expected physiological variation.
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