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 C

Explanation

A. Keeping both arms below the level of the client's heart is not recommended for preventing lymphedema. The affected arm should be elevated when possible to reduce the risk of fluid accumulation.
B. Obtaining blood pressure readings on the affected arm is contraindicated because it can increase the risk of lymphedema.
C. Use the client's left arm to obtain blood samples: To prevent lymphedema, it's important to avoid using the affected arm (the right arm in this case) for invasive procedures like blood draws or blood pressure measurements, as this can increase the risk of lymphedema by promoting fluid retention.
D. Limiting range-of-motion exercises could impair recovery and muscle function. Early and gentle exercises should be encouraged to maintain mobility and avoid complications.

A. Start the prescribed antibiotic B. Discontinue nasogastric tube C. Reinforce preoperative teaching D. Provide the client with ice chips

Correct Answer is C

Explanation

A. Start the prescribed antibiotic: There is no indication of infection in the current clinical findings; antibiotics are typically used to treat bacterial infections, which are not yet evident.
B. Discontinue nasogastric tube: The nasogastric tube should remain in place as it helps relieve the symptoms of small bowel obstruction (e.g., vomiting and bloating).
C. Reinforce preoperative teaching: The client is on NPO status, which may suggest preparation for a surgical intervention to address the obstruction. Reinforcing preoperative teaching would be beneficial to ensure the client understands the procedure.
D. Provide the client with ice chips: The client is on NPO status, and consuming food or fluids is contraindicated due to the potential for aspiration or worsening of the condition (e.g., bowel obstruction or pancreatitis).

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

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