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 A
Explanation
A. Correct. Informed consent means the client has the right to refuse treatment even after giving initial consent. The nurse should respect the client's autonomy and decision.
B. Incorrect. This statement does not respect the client's right to make decisions about her treatment.
C. Incorrect. While this statement might be true for some individuals, it does not address the client's current hesitation and does not respect her autonomy.
D. Incorrect. This statement does not address the client's expressed hesitation about the treatment.
Correct Answer is A
Explanation
Choice A rationale:
Diazepam is a benzodiazepine medication commonly used to manage seizures, including those associated with alcohol withdrawal. It acts as a central nervous system depressant, reducing excessive neuronal activity and helping control seizures. Diazepam is considered the first-line medication for managing alcohol withdrawal seizures due to its efficacy and safety profile when administered under medical supervision.
Choice B rationale:
Naltrexone is an opioid receptor antagonist used primarily to treat alcohol and opioid dependence. It does not have a direct anticonvulsant effect and is not indicated for managing seizures associated with alcohol withdrawal. Naltrexone works by blocking the effects of opioids and reducing cravings, making it valuable in substance use disorder treatment but not in the acute management of seizures.
Choice C rationale:
Acamprosate is another medication used in the treatment of alcohol dependence. It helps maintain abstinence from alcohol by reducing cravings and withdrawal symptoms. However, it does not have anticonvulsant properties and is not used to manage seizures associated with alcohol withdrawal. Acamprosate is more focused on supporting long-term sobriety and preventing relapse in individuals
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