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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Deep breathing is a relaxation technique that can help reduce pain by increasing oxygen delivery, decreasing muscle tension, and promoting a sense of calmness. The nurse should instruct the client to breathe slowly and deeply through the nose and exhale through the mouth.
B. Heat therapy may provide relief for muscle-related back pain but should not be applied for prolonged periods as it may cause tissue damage.
C. Minimizing environmental stimuli can help the client focus on relaxation techniques and alleviate pain perception but is not as effective as deep breathing.
D. Ice therapy is typically used for acute pain or inflammation and may not be appropriate for mild, ongoing back pain.

A. Obtain the client's type and cross-match. B. Inform the provider of the delay in obtaining the type and cross-match. C. Document the incident in the client's medical record. D. Prepare an incident report for risk management.

Correct Answer is A

Explanation

A. Obtaining the client's type and cross-match is the first action the nurse should take because it ensures that the client will have compatible blood available for transfusion if needed during surgery.
B. This is important but should only be done after obtaining the client’s type and cross-match.
C. This should be done after obtaining the client’s type and cross-match.

D. While an incident report may be necessary, the immediate priority is to address the oversight and ensure patient safety.

View Question and Answer

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

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 planning to use nonpharmacological pain relief methods for a client who reports continued mild back pain after receiving analgesia 1 hr ago. Which of the following actions should the nurse include in the plan?

Correct Answer is A

Explanation

During change-of-shift report, a nurse discovers they overlooked a prescription for a type and cross-match of a client who is to have surgery the next day. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A home health nurse is caring for a group of older adult clients. Which of the following statements by a client is an indication they may be experiencing social isolation?

A home health nurse is performing a fall risk assessment for an older adult client. Which of the following findings should the nurse identify as a potential fall risk in the home?

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

A nurse is assessing a client who recently started taking an antibiotic. The nurse should identify that which of the following findings is an indication of a mild allergic reaction?

A community health nurse is caring for a group of families. The nurse should identify that which of the following families is experiencing a maturational loss?

A nurse is administering a medication to a client. The nurse identifies the client has an allergy to the medication after it has been administered. Which of the following actions should the nurse take?

A nurse is administering multiple types of ophthalmic drops to a client. Which of the following actions should the nurse take?

A nurse is providing discharge teaching to a client who is at risk for falls. Which of the following information should the nurse include in the teaching?