A nurse is completing discharge teaching about ostomy care with a client who has a new stoma. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
"Empty the ostomy pouch when it becomes one-third full of contents."
"Expect the stoma to turn a purple-blue color as it heals."
"Place a piece of gauze over the stoma while changing the pouch."
"Cut the opening of the pouch 1/8 of an inch larger than the stoma."
"Use povidone-iodine to clean around the stoma."
Correct Answer : A,D
Rationale
A. "Empty the ostomy pouch when it becomes one-third full of contents.": Emptying the pouch before it becomes too full prevents leakage, skin irritation, and discomfort. Regular emptying supports hygiene and maintains appliance adherence, which is essential for stoma care.
B. "Expect the stoma to turn a purple-blue color as it heals.": A healthy stoma should be pink to red, indicating good perfusion. Purple-blue discoloration may indicate ischemia or compromised blood flow, which requires immediate provider notification.
C. "Place a piece of gauze over the stoma while changing the pouch.": Gauze is not necessary and may interfere with proper pouch application. Direct handling with clean technique and using the appliance as designed is sufficient for maintaining hygiene and protecting the stoma.
D. "Cut the opening of the pouch 1/8 of an inch larger than the stoma.": Ensuring the pouch opening is slightly larger than the stoma protects peristomal skin from contact with effluent while maintaining a secure fit. Accurate sizing is critical for preventing skin breakdown and leakage.
E. "Use povidone-iodine to clean around the stoma.": Povidone-iodine is harsh and can irritate peristomal skin. Gentle washing with warm water and mild soap is recommended to preserve skin integrity and prevent irritation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale
A. Contact: Contact precautions are used for infections spread by direct or indirect contact, such as C. difficile or MRSA. Measles is not primarily transmitted via contact, so contact precautions alone are insufficient.
B. Airborne: Measles is highly contagious and transmitted via airborne respiratory droplets that can remain suspended in the air. Airborne precautions, including placing the client in a negative-pressure room and requiring staff to wear N95 respirators, are necessary to prevent transmission.
C. Protective: Protective (or neutropenic) precautions are designed to protect immunocompromised clients from infection. They are not appropriate for preventing the spread of measles from an infected client.
D. Droplet: Droplet precautions are used for infections spread by larger respiratory droplets, such as influenza or pertussis. Measles requires airborne precautions because the virus can travel on smaller particles and remain suspended in the air for extended periods.
Correct Answer is B
Explanation
Rationale
A. Keep the head of the bed flat: Keeping the head of the bed flat is not necessary when preparing a body for family viewing. Elevating the head slightly may provide a more natural appearance, but bed positioning does not impact the safety or dignity of the viewing.
B. Hold the client's eyelids closed until they remain shut: After death, the eyes may remain partially open, which can be distressing for the family. Gently holding the eyelids closed until they stay shut helps maintain a peaceful and natural appearance, promoting dignity and reducing potential emotional trauma during viewing.
C. Apply identification tags to the client's extremities: Identification tags are applied for legal and procedural purposes, usually by the mortuary or following facility protocol. While important, this action does not directly prepare the body for family viewing and can be completed afterward.
D. Leave resuscitation equipment and supplies at the bedside: Leaving used resuscitation equipment at the bedside is inappropriate and may be distressing to the family. All supplies should be removed or stored out of sight before family viewing to preserve a respectful environment and maintain dignity.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.