A nurse is reinforcing teaching about ostomy supplies with a client who has a new colostomy. Which of the following information should the nurse include?
Empty the pouch when it is 1/3 to 1/2 full.
Use a standard enema set to irrigate the colostomy.
Cleanse the skin surrounding the stoma with moisturizing soap.
Cut the opening in the skin barrier 1/4 inch larger than the stoma.
The Correct Answer is A
A. Empty the pouch when it is 1/3 to 1/2 full: This prevents the weight of the pouch from causing leaks or pulling on the stoma.
B. Use a standard enema set to irrigate the colostomy: This is incorrect as a standard enema set is not typically used. Colostomy irrigation requires specific equipment and is not performed routinely.
C. Cleanse the skin surrounding the stoma with moisturizing soap: Moisturizing soap can leave a residue that interferes with adhesive barriers. Mild, non-moisturizing soap or just water should be used.
D. Cut the opening in the skin barrier 1/4 inch larger than the stoma: The opening should fit closely to the stoma to protect the surrounding skin from irritation and leakage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Canola oil.": Canola oil is low in saturated fats and high in monounsaturated fats, which are heart-healthy and help reduce cardiovascular risk.
B. "Butter.": Butter contains high levels of saturated fats, which can increase LDL cholesterol.
C. "Vegetable shortening.": Shortening contains trans fats, which are harmful to cardiovascular health.
D. "Lard.": Lard is high in saturated fats and is not recommended for individuals at risk of cardiovascular disease.
Correct Answer is D
Explanation
A. Muscle spasms: These are not typically associated with DVT.
B. Absent pedal pulse: This suggests arterial occlusion, not venous thrombosis.
C. Numbness of the affected extremity: Numbness is not a classic sign of DVT and might indicate a nerve-related issue.
D. Warmth of the affected extremity. Warmth is a hallmark sign of DVT due to localized inflammation and impaired venous circulation.
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