A nurse is reinforcing discharge teaching with a client about how to care for a newly created ileal conduit. Which of the following instructions should the nurse include in the teaching?
Change the ostomy pouch daily.
Empty the ostomy pouch when it is 2/3 full.
Trim the opening of the ostomy seal to be 1/2 inch wider than the stoma.
Apply lotion to the peristomal skin when changing the ostomy pouch.
The Correct Answer is B
Choice A reason: Changing the ostomy pouch daily is not typically necessary. Most pouches can be worn comfortably for several days before needing to be changed. Frequent changes are not only unnecessary but can also irritate the skin around the stoma.
Choice B reason: Emptying the ostomy pouch when it is 2/3 full is recommended to prevent leaks and overfilling, which can lead to discomfort and potential skin irritation. It is important to monitor the fullness of the pouch and empty it regularly to maintain hygiene and comfort.
Choice C reason: Trimming the opening of the ostomy seal to be 1/2 inch wider than the stoma is incorrect. The opening should be cut to match the size of the stoma to ensure a snug fit that prevents leakage and protects the skin around the stoma.
Choice D reason: Applying lotion to the peristomal skin when changing the ostomy pouch is not advised. Lotions or creams can interfere with the adhesive of the ostomy appliance and should be avoided. The peristomal skin should be clean and dry to ensure proper adhesion of the ostomy appliance.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason : Displaying a monthly calendar can help orient a client with Alzheimer's disease to the date and assist with maintaining a sense of time, which can be beneficial in managing cognitive impairment.
Choice B reason: Providing plenty of stimulation can be overwhelming for clients with Alzheimer's disease. A calm and predictable environment is usually more beneficial.
Choice C reason: Keeping the room dark at night can promote sleep, but it is not the only consideration. A nightlight or low-level lighting can prevent falls if the client needs to get up during the night.
Choice D reason: Providing structured activities can help fill the client's time and provide a sense of purpose, but it should be tailored to the individual's abilities and preferences.
Correct Answer is A
Explanation
Choice A reason: Drawing the regular insulin into the syringe first is correct. When mixing two types of insulin, the clear (regular) insulin should be drawn up before the cloudy (NPH) insulin to prevent contamination.
Choice B reason: Storing prefilled syringes with the needle pointed upward can cause air bubbles to move into the insulin, which can alter the dose when injected. The needle should be pointed downward.
Choice C reason: Shaking the NPH vial vigorously is not recommended as it can create air bubbles and affect the insulin dose. Instead, the vial should be gently rolled between the hands to mix the insulin.
Choice D reason: Inserting the needle at a 15-degree angle is incorrect for subcutaneous injections. A 90-degree angle is typically used unless the patient is very thin, in which case a 45-degree angle may be used.
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