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.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The dropper should be held about 1 cm (0.4 in) away from the eye to avoid touching or injuring the eye or contaminating the dropper tip.
B. Massaging the eyelids after instillation is not a standard practice and may cause discomfort or injury to the eye.
C. Administering multiple ophthalmic medications requires a sufficient interval between doses to prevent interactions and ensure effectiveness.
D. Asking the client to close their eyes tightly may squeeze out some of the medication or increase intraocular pressure.
Correct Answer is C
Explanation
A. Clean gloves are typically sufficient for wound care, and the use of sterile gloves may not be necessary for routine dressing changes.
B. Frequent dressing changes can disrupt wound healing and increase the risk of infection. Dressings should be changed according to the healthcare provider's instructions, which are typically less frequent.
C. When cleaning the wound, it is important to start from the incision site and work outward to avoid introducing contaminants into the wound.
D. Tincture of benzoin is a skin adhesive and may not be routinely used for dressing changes, especially if it is not specified in the healthcare provider's orders.
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