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."
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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Related Questions
Correct Answer is C
Explanation
A. Using the room number to identify a patient is not reliable since many clients may share it.
B. The telephone number is not typically used for client identification during assessments.
C. The nurse should use the client's name to properly identify the client before performing any assessment or intervention. This is a standard safety measure that helps to prevent errors and ensure quality care.
D. The diagnosis is important for providing appropriate care but is not used for client identification during assessments.
Correct Answer is B
Explanation
A. Social workers typically assist with psychosocial issues, resource management, and support services. While important, they may not have the specialized skills required for teaching eating utensil use.
B. Occupational therapists specialize in helping individuals regain the ability to perform activities of daily living, including eating, after injuries such as traumatic brain injury.
C. Speech-language pathologists focus on communication and swallowing disorders.
While they may be involved in therapy for clients with traumatic brain injury, their primary focus is not on teaching utensil use.
D. Physical therapists focus on mobility, strength, and function. While they may assist with overall rehabilitation after a traumatic brain injury, they are not specifically trained in teaching eating skills.
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