A nurse is creating a plan of care to maintain the skin integrity of a client who experiences frequent diarrhea due to ulcerative colitis. Which of the following interventions should the nurse include in the plan?

Administer a soap-suds enema to cleanse the colon.

Soak in a sitz bath for 20 min after each stool.

Wipe perianal area with warm water and apply a barrier cream.

Cleanse with antimicrobial scrub and vigorously dry.

Answer and Explanation

The Correct Answer is C

A. Soap-suds enemas are not recommended for clients with ulcerative colitis because they can irritate the colon and worsen symptoms. Enemas should be used cautiously, if at all, and only when medically indicated.
B. Soaking in a sitz bath can help soothe perianal discomfort, but it is not the most effective intervention for protecting the skin from diarrhea-related irritation. Barrier creams are a more direct way to protect the skin from further damage.
C. Wiping the perianal area with warm water and applying a barrier cream is an appropriate and effective intervention to protect the skin. The warm water is gentle, and the barrier cream provides a protective layer that helps prevent skin breakdown from frequent contact with stool.
D. Cleansing with an antimicrobial scrub and vigorously drying the perianal area could cause further irritation and damage to already sensitive skin. The focus should be on gentle cleansing and protecting the skin with a barrier cream.

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Correct Answer is C

Explanation

A. A rosebud-like stoma orifice is a normal finding. It refers to a stoma that has a rounded, pink appearance, which is healthy and typical after surgery.
B. A shiny, moist stoma is a normal finding. This appearance indicates good circulation and healing.
C. A purplish-colored stoma is abnormal and should be reported to the provider immediately. This color suggests possible ischemia or poor circulation, which may require intervention to prevent complications such as necrosis of the stoma.
D. Stoma oozing red drainage is normal, especially in the early postoperative period. It indicates that the stoma is healing properly. However, if the drainage is excessive or if the client shows signs of infection, it would need further evaluation.

A. Apply petroleum jelly to the nares as needed to soothe mucous membranes. B. Attach a humidifier bottle to the base of the flow meter. C. Remove the nasal cannula while the client eats. D. Secure the oxygen tubing to the bed sheet near the client's head.

Correct Answer is B

Explanation

A. Petroleum jelly should not be used on the nares with oxygen therapy, as it is flammable and could pose a fire hazard. Non-petroleum-based lubricants should be used if needed.
B. A humidifier should be attached to the flow meter when delivering oxygen at higher flow rates (such as 6 L/min) to prevent dryness and irritation of the mucous membranes in the nose and throat.
C. The nasal cannula should generally be kept on during meals to ensure continued oxygen therapy, unless it is uncomfortable or the client has other medical needs.
D. The oxygen tubing should be secured to the client’s body or clothing in a way that does not restrict movement or cause injury, but securing it to the bed sheet could lead to a potential tripping hazard or interfere with mobility.

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A nurse is creating a plan of care to maintain the skin integrity of a client who experiences frequent diarrhea due to ulcerative colitis. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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