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.

Answer and Explanation

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.

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Correct Answer is ["A","B","E"]

Explanation

A. Current medication prescriptions: Ensures continuity of care and proper medication administration in the ICU.
B. Primary health problem: Provides the ICU team with context about the client’s current condition and reason for transfer.
C. Number of family members who have visited: This is not clinically relevant to the client's care.
D. Admission vital signs from 1 week ago: Historical vitals are not as critical as current or recent findings.
E. Scheduled times for dressing changes: Provides critical information about ongoing wound care needs.

A. Pain level B. Social history C. Skin findings D. Lipase level E. WBC count F. Abdominal findings

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A,B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

Pain level:

Small bowel obstruction: The client reports mid-abdominal pain, which is characteristic of small bowel obstruction as the pain is often crampy and located around the abdomen.
Acute pancreatitis: Abdominal pain is also a common symptom of acute pancreatitis, typically described as severe and persistent.

Social history:

Small bowel obstruction: Alcohol consumption is not a typical cause of obstruction.
Acute pancreatitis: Chronic alcohol use is a major risk factor for acute pancreatitis.

Skin findings:

Small bowel obstruction: Skin findings are usually unaffected.
Acute pancreatitis: In severe cases, pancreatic enzymes can leak into the skin, leading to ecchymosis (e.g., Grey Turner's or Cullen's sign). While jaundice can occur in acute pancreatitis due to bile duct obstruction, its absence does not rule out the condition.

Lipase level:

Small bowel obstruction: Lipase is generally normal.
Acute pancreatitis: Elevated lipase levels are highly indicative of acute pancreatitis.

WBC count:

Small bowel obstruction: A mild increase in WBC may occur due to bowel distension. The client’s WBC count is 9,000/mm³, which is within the normal range.
Acute pancreatitis: WBC levels are often elevated due to inflammation.

Abdominal findings:

Small bowel obstruction: Tenderness and high-pitched bowel sounds are typical signs.
Acute pancreatitis: Abdominal tenderness can also be present in acute pancreatitis, but high-pitched bowel sounds are more specific to small bowel obstruction.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the transfer of a client from a medical-surgical unit to an intensive care unit following a change in status. Which of the following information should the nurse include in the transfer documentation? (Select all that apply.)

Correct Answer is ["A","B","E"]

Explanation

The nurse is assisting with the care of a client. Exhibits For each finding, click to specify if the finding is consistent with small bowel obstruction or acute pancreatitis. Each finding may support more than 1 disease process.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A,B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

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