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. Perform suctioning: Restlessness and crackles in the lungs may indicate retained secretions. Suctioning the tracheostomy can help clear secretions and improve oxygenation.
B. Instill saline into the tubing: Routine instillation of saline is not recommended as it can cause discomfort, dislodge bacteria, or create a risk of aspiration.
C. Increase the humidification: While humidification helps prevent mucus from becoming thick, it does not address the immediate issue of retained secretions causing crackles.
D. Check the cuff pressure: While it is important to ensure appropriate cuff pressure, this is not the primary intervention for resolving restlessness and crackles, which suggest secretion buildup.
Correct Answer is A
Explanation
A. "Replace wet clothing with warmed blankets.": Hypothermia is a significant concern after near-drowning in cold conditions. Replacing wet clothing with warmed blankets helps stabilize body temperature.
B. "Use an axillary thermometer to monitor the client's temperature.": Axillary thermometers are not accurate for hypothermic clients. Core temperature monitoring is more reliable.
C. "Assist the client to perform range-of-motion exercises.": This is not a priority in acute care following hypothermia or near-drowning.
D. "Administer an antihypertensive medication.": Hypertension is not the focus unless specific cardiovascular conditions are present.
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