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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
A. The nurse's signature confirms that the client signed the informed consent document in the nurse's presence, verifying that the client provided consent voluntarily.
B. The nurse's signature confirms that the client has legal capacity and authority to provide consent for the proposed treatment or procedure.
C. The nurse's signature does not confirm the absence of a mental health condition; rather, it confirms that the client has provided informed consent.
D. The nurse's signature confirms that the client provided consent voluntarily and was not coerced or unduly influenced to do so.
E. While it is important for the client to understand the information provided, the nurse's signature does not specifically confirm this requirement.
Correct Answer is D
Explanation
A. This action may increase the risk of injury to both the nurse and the client.
B. This action does not effectively prevent the fall or minimize injury.
C. Moving quickly to a position in front of the client can cause imbalance and increase the risk for falling.
D. Allowing the client to slide down their outstretched leg can help prevent injury to both the client and the nurse.
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