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 E,C,D,B,A
Explanation
Choice E Reason:
Preparing a dry work surface above the waist level. It's crucial to start by selecting and preparing an appropriate area for setting up the sterile field. This surface needs to be clean, dry, and above the waist level to maintain sterility and prevent contamination.
Choice C Reason:
Opening the outside cover of the sterile kit and remove the dust cover. This step involves opening the sterile kit without touching the inside contents to maintain sterility. Removing the outer cover exposes the sterile packaging and prepares for further steps.
Choice D Reason:
Grasping the outermost flap of the sterile kit while opening away from the body. By carefully opening the outermost flap, the nurse ensures that the sterile contents remain protected. Opening away from the body helps prevent accidental contamination from clothing or movements.
Choice B Reason:
Opening each side flap of the sterile kit individually while pulling to the side. Sequentially opening the side flaps maintains the sterile field and allows access to the inner contents without compromising sterility.
Choice A Reason:
Opening the innermost lower flap of the sterile kit while standing away from the sterile field. This final step involves accessing the innermost contents of the sterile kit while maintaining a safe distance to avoid accidental contamination. It ensures the contents within the sterile field remain protected until needed for the dressing change.
Correct Answer is C
Explanation
Choice A Reason:
Turning the hearing aid off for 5 min is inappropriate. Turning off the hearing aid may not address the underlying issue of feedback. Adjusting the volume or checking for proper placement is more appropriate.
Choice B Reason:
Cleaning the hearing aid with isopropyl alcohol is inappropriate. While cleaning the hearing aid is important for maintenance, using isopropyl alcohol may damage certain components. It's generally recommended to use a specialized cleaning solution recommended by the hearing aid manufacturer.
Choice C Reason:
Decreasing the volume on the hearing aid is appropriate. The whistling sound, also known as feedback, can occur when the volume is set too high. Lowering the volume should help alleviate the feedback and improve the client's experience with the hearing aid.
D. Soak the hearing aid in warm water.
Soaking a hearing aid in water is not recommended, as it can damage the electronic components. Hearing aids are sensitive to moisture, and water exposure can lead to malfunction.
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