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 A
Explanation
Choice A Reason:
“I understand that you decided not to receive blood products.” This response shows empathy and acknowledges the client's decision without judgment. It respects the client's autonomy and decision-making capacity.
Choice B Reason:
“Not receiving blood will slow down your memory.” This statement introduces a potential consequence that may not be accurate or relevant to the client's decision. It is important to provide information, but scare tactics or inaccurate statements may not be helpful.
Choice C Reason:
“Why are you refusing to receive blood products?” While understanding the client's rationale is essential, the initial response should convey empathy and acceptance. Asking why may be appropriate later in the conversation, but starting with understanding is crucial.
Choice D Reason:
“You need to talk with your doctor about this.” While involving the doctor is important, it's essential to address the client's feelings and decisions directly. The nurse can play a supportive role in facilitating communication between the client and the healthcare team.
Correct Answer is B
Explanation
Choice A Reason:
Inflating the catheter's balloon is inappropriate. Inflating the balloon at this point is not recommended. The balloon should only be inflated once the catheter is in the bladder and urine starts to flow.
Choice B Reason:
Twisting the catheter gently is appropriate. Twisting the catheter gently may help navigate any obstruction or resistance within the urethra. However, it is crucial to be cautious and not force the catheter. If resistance persists or if the catheter cannot be advanced further, the nurse should reassess the situation and consider alternative actions, such as selecting a smaller catheter or seeking assistance from a more experienced healthcare provider.
Choice C Reason:
Applying lidocaine gel to the urethra is inappropriate. Applying lidocaine gel may be appropriate for lubrication and to minimize discomfort during catheter insertion, but it will not address the issue of resistance or lack of urine flow.
Choice D Reason:
Lowering the penis to a 45° angle is inappropriate. Adjusting the angle of the penis is not likely to resolve the issue of resistance. Twisting the catheter gently or reassessing the situation would be more appropriate.
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