A nurse is providing discharge teaching to a client who has a new ostomy.
Which of the following instructions should the nurse include?
"Apply sterile gloves when changing your ostomy pouch.”
"Notify the provider if your stoma becomes pink and moist.”
"Empty your ostomy pouch when it is half full.”
"Use a moisturizing soap to cleanse your stoma.”
The Correct Answer is C
Choice A rationale:
Applying sterile gloves when changing the ostomy pouch is essential for infection control. However, this is a standard practice and not specific to the client's condition. While important, it is not the priority instruction for a client with a new ostomy.
Choice B rationale:
Notifying the provider if the stoma becomes pink and moist is crucial information for the client. A pink and moist stoma indicates good blood supply and healing, while changes in color or moisture might indicate complications. This instruction is essential for the client's ongoing care and to prevent potential complications, making choice B the correct answer.
Choice C rationale:
Emptying the ostomy pouch when it is half full is a general guideline to prevent leakage and maintain hygiene.
Choice D rationale:
Soaps with lotions or perfumes may interfere with the pouch seal or cause peristomal skin irritation. Rinse and dry well.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Incorrect. Acting seductively is more characteristic of histrionic personality disorder.
B. Incorrect. Being overly concerned about minor details is more characteristic of obsessive-compulsive personality disorder.
C. Correct. Impulsive behavior, such as reckless spending or self-harm, is a common feature of borderline personality disorder.
D. Incorrect. Being exceptionally clingy to others is not a defining feature of borderline personality disorder.
Correct Answer is ["C","D","G"]
Explanation
Based on the provided information, the nurse should include the following statements in the client's teaching:
C. "Wear loose-fitting clothing": This is because the specific gravity of the urine is slightly elevated (1.022), which may indicate mild dehydration. Loose-fitting clothing can help promote comfort and ventilation, especially in cases of dehydration.
D. "Wear flat or low-heeled shoes": There is no specific indication related to the urine dipstick results, but it is generally good advice for maintaining proper foot health and preventing strain on the feet and ankles.
G. "You should avoid fried foods": There are no specific indications related to the urine dipstick results, but a healthy diet is always beneficial for overall well-being. Avoiding fried foods can be a part of a balanced diet and promote better health.
The following statements should not be included in the client's teaching based on the provided urine dipstick results:
A. "Try using an abdominal support belt": There is no indication related to the urine dipstick results that suggests the need for an abdominal support belt.
B. "Take hot showers to help relieve itching": Itching is not mentioned in the urine dipstick results, so there is no specific indication to recommend hot showers for this purpose.
E. "You can douche twice weekly": Douche is not related to urine dipstick results, and douching is generally not recommended as it can disrupt the natural balance of vaginal flora and may cause more harm than good.
F. "Eat two large meals a day": There is no indication related to the urine dipstick results that suggests a specific meal plan, and eating two large meals a day may not be suitable for everyone's dietary needs.
It's important for the nurse to provide teaching based on the client's specific needs and health conditions. In this case, the nurse can focus on maintaining hydration (based on the specific gravity result) and promoting a balanced diet and healthy lifestyle. Always individualize teaching based on the client's health status and any specific concerns they may have.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.