A nurse is reinforcing teaching with a client about caring for a new colostomy. Which of the following statements should the nurse make?
"You should scrub the skin around the colostomy when cleaning."
"You can use an adhesive remover when changing the colostomy skin barrier."
"You will need a device to suction stool from the colostomy bag."
"You should empty the colostomy bag when it is three-fourths full."
The Correct Answer is B
b. "You can use an adhesive remover when changing the colostomy skin barrier."
The nurse should inform the client that they can use an adhesive remover when changing the colostomy skin barrier. Adhesive removers are helpful in gently removing the adhesive residue left behind by the previous ostomy appliance. This can make the process of changing the colostomy skin barrier more comfortable for the client and help prevent skin irritation or damage.
Explanation for the other options:
a. "You should scrub the skin around the colostomy when cleaning." Scrubbing the skin around the colostomy can be harsh and may cause skin irritation or damage. It is recommended to clean the peristomal skin gently using mild soap and water, followed by thorough drying.
c. "You will need a device to suction stool from the colostomy bag." Suctioning stool from the colostomy bag is not a routine procedure for colostomy care. Colostomy bags are designed to collect stool, and emptying the bag as needed is the appropriate method of management.
d. "You should empty the colostomy bag when it is three-fourths full." The timing of emptying the colostomy bag may vary for each individual. It is generally recommended to empty the colostomy bag when it is one-third to one-half full to prevent leakage or discomfort. The client should be educated on monitoring the bag and emptying it as necessary based on their own output and comfort level.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Placenta previa is a condition where the placenta partially or completely covers the opening of the cervix. One of the hallmark signs of placenta previa is painless vaginal bleeding, typically bright red in color. This bleeding can occur spontaneously or during activities that put pressure on the uterus, such as sexual intercourse or physical exertion.
A rigid abdomen is not typically associated with placenta previa. It may indicate other conditions, such as peritonitis or abdominal muscle rigidity, but it is not a characteristic finding of placenta previa.
Persistent uterine contractions are not typically associated with placenta previa. Placenta previa is more commonly associated with painless bleeding rather than contractions. However, if placenta previa is complicated by other factors, such as placental abruption, contractions and abdominal pain may be present.
Fetal movement is not directly related to placenta previa. Fetal movement can vary from person to person and does not specifically indicate placenta previa. However, it is important for the nurse to assess fetal well-being in clients with placenta previa as bleeding can impact the oxygen supply to the fetus.
Correct Answer is B
Explanation
The correct answer is b. "I will apply petroleum jelly to the penis with each diaper change."
Choice A rationale:
- It is incorrect to focus on removing all yellow exudate.A small amount of yellow exudate is normal during the healing process after circumcision.Attempting to aggressively clean it off can irritate the delicate healing tissues and cause discomfort for the baby.
- Instead,parents should gently cleanse the area with warm water during diaper changes,allowing any mild exudate to naturally drain.
Choice B rationale:
- Applying petroleum jelly with each diaper change is an essential step in promoting healing and preventing discomfort after circumcision.Here's why:
- Protects against moisture:Petroleum jelly forms a barrier that protects the delicate healing tissues from moisture from urine and feces.This helps to prevent irritation and keeps the area clean.
- Reduces friction:The lubricating properties of petroleum jelly reduce friction between the penis and the diaper,which can minimize discomfort and pain for the baby.
- Promotes healing:Petroleum jelly creates a moist environment that promotes healing and reduces scab formation.This helps the circumcision site to heal faster and more comfortably.
Choice C rationale:
- While ensuring a proper diaper fit is important for overall hygiene,it's not the most crucial aspect of post-circumcision care.A snug diaper can put unnecessary pressure on the healing penis,potentially causing irritation and discomfort.It's generally recommended to choose a diaper that fits comfortably without being too tight.
Choice D rationale:
- Using soap to wash the penis is not recommended during the healing process.Soap can be harsh and drying to the delicate tissues,potentially causing irritation and delaying healing.
- Warm water is sufficient for cleansing the area during diaper changes.
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