A nurse is reinforcing teaching with a client who has an ostomy. Which of the following statements by the client indicates an understanding of the teaching?
"I will press on the skin barrier for 30 seconds to ensure that it adheres."
"I will clean around the stoma with a moisturizing soap."
"I will apply a thin layer of talc powder around the stoma before placing the appliance."
"I will cut an opening in the skin barrier that is 1⁄2 inch larger than the stoma."
The Correct Answer is A
Choice A Reason:
Pressing on the skin barrier for about 30 seconds ensures that it adheres properly to the skin, which helps secure the ostomy appliance and prevents leakage.
Choice B Reason:
Moisturizing soap is not recommended for cleaning around the stoma, as it can leave a residue that interferes with the appliance's adhesion. Mild soap without moisturizers or just water should be used.
Choice C Reason:
Applying talc powder around the stoma can prevent the appliance from adhering properly, leading to leakage. It is not recommended for ostomy care.
Choice D Reason:
The skin barrier should be cut to fit closely around the stoma, leaving no more than a 1/8 inch gap, not 1/2 inch. A larger opening may cause skin irritation or leakage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Administering sedative medication should not be the first action. It is important to assess the client's level of comfort and understand the reason for pulling on the NG tube before considering sedation. Sedation may mask underlying issues, and the goal is to address the cause of the behavior.
Choice B Reason:
Assessing the client's level of comfort is the priority. Understanding the reason for pulling on the NG tube is crucial before implementing interventions. The client may be experiencing pain, discomfort, anxiety, or another issue that needs to be addressed.
Choice C Reason:
Applying a restraint should be a last resort and is not the initial action. Restraints are used to ensure safety when other measures have failed. The priority is to address the underlying cause and promote comfort without resorting to restraint.
Choice D Reason:
Documenting the client's behavior is important for the medical record, but it comes after assessing and addressing the immediate needs of the client. Understanding the context and reasons for the behavior is crucial for accurate documentation.
Correct Answer is A
Explanation
Choice A Reason:
Placing the drainage system below the client's chest level is appropriate. This positioning allows for proper drainage and prevents the backflow of fluid or air into the chest. Maintaining the drainage system below the chest level helps ensure effective evacuation of air or fluid from the pleural space.
Choice B Reason:
Looping excess tubing next to the client's side is inappropriate. Looping excess tubing can create dependent loops, potentially causing fluid to accumulate in these areas and compromising the drainage system's effectiveness.
Choice C Reason:
Clamping the tubing when ambulating the client is inappropriate. Chest tube drainage systems should not be routinely clamped during ambulation. Clamping can lead to increased pleural pressure, potentially causing tension pneumothorax or other complications.
Choice D Reason:
Milking the client's tubing every shift is inappropriate. Milking or stripping the tubing is not recommended, as it can create a pressure gradient that may damage the lung tissue or disrupt the chest tube's seal. Passive drainage is preferred to maintain the negative pressure in the system.
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