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.)

"Use povidone-iodine to clean around the stoma."

"Cut the opening of the pouch / of an inch larger than the stoma."

"Empty the ostomy pouch when it becomes one-third full of contents."

"Place a piece of gauze over the stoma while changing the pouch."

"Expect the stoma to turn a purple-blue color as it heals."

Answer and Explanation

Correct Answer : B,C,D

A.   Povidone-iodine is not recommended for cleaning around the stoma as it may cause irritation.
B.   Ensuring the pouch opening is slightly larger than the stoma helps prevent irritation and ensures proper fit.
C.   Regular emptying of the ostomy pouch prevents leakage and skin irritation. It also prevents it from becoming too heavy and pulling away from the skin.
D.   The nurse should advise the client to place a piece of gauze over the stoma while changing the pouch to protect it from injury and contamination.
E.   A purplish-blue change in the stoma is an indication of impaired blood supply to the stoma and should be promptly reported to the healthcare provider.

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Correct Answer is ["A","C","D"]

Explanation

A. This abbreviation can be misinterpreted as "units," "cc," or "you." It is recommended to avoid its use to prevent misinterpretation.
B. This abbreviation stands for intake and output, which is commonly used in healthcare documentation and is not on The Joint Commission's Do Not Use list.
C. IU can be mistaken for intravenous or international unit.

D. This abbreviation stands for once daily and is prone to misinterpretation, as it can be mistaken for qid (four times daily). It is recommended to avoid its use to prevent dosing errors.
E. This abbreviation stands for pro re nata, indicating "as needed" medication administration, and is not on The Joint Commission's Do Not Use list.

A. The client's pupils constrict in response to light. B. The client's tongue is in a midline position: C. The client has a symmetrical smile. D. The client turns their head against resistance.

Correct Answer is C

Explanation

A. This response is associated with cranial nerve II, the optic nerve.

B. Tongue position is associated with cranial nerve XII, the hypoglossal nerve.

C. A symmetrical smile is indicative of cranial nerve VII, the facial nerve.

D. This action is associated with cranial nerve XI, the accessory nerve.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to document in the client's medical record. The nurse should identify that which of the following abbreviations are specified by The Joint Commission for placement on a facility's Do Not Use list? (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

A nurse is assessing a client's cranial nerve VII. Which of the following responses should the nurse expect?

Correct Answer is C

Explanation

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