A nurse is reinforcing teaching with another nurse about how change an ostomy appliance for a client who has sigmoid colostomy. Which of the following instructions should the nurse include in the teaching?
Use a moisturizing soap to clean the skin around the client's stoma.
Create an opening on the skin barrier that is 1.27 cm (0.5 in) larger than the client's stoma.
Empty the client's ostomy pouch before removing the skin barrier.
Change the client's ostomy appliance hr after breakfast.
The Correct Answer is C
A) Use a moisturizing soap to clean the skin around the client's stoma:
Using a moisturizing soap is not recommended for cleaning the skin around the stoma. Moisturizing soaps can leave a residue that may interfere with the adhesion of the ostomy appliance. The skin around the stoma should be cleaned with warm water and mild soap that does not contain lotions, fragrances, or oils. This helps ensure the skin is clean and dry, promoting better adhesion of the skin barrier.
B) Create an opening on the skin barrier that is 1.27 cm (0.5 in) larger than the client's stoma:
The opening in the skin barrier should be about 1/8 inch (approximately 0.32 cm) larger than the stoma's diameter, not 1.27 cm (0.5 in) larger. A larger opening can cause the skin barrier to fit too loosely, leading to leakage and skin irritation. The skin barrier should fit snugly around the stoma to prevent any leakage and protect the surrounding skin.
C) Empty the client's ostomy pouch before removing the skin barrier:
It is essential to empty the ostomy pouch before removing the skin barrier to prevent fecal material from spilling or leaking during the appliance change. This helps maintain cleanliness, reduces the risk of skin irritation, and makes the procedure more comfortable for both the client and the nurse.
D) Change the client's ostomy appliance 1 hour after breakfast:
There is no specific time required after breakfast to change the ostomy appliance. The timing of appliance changes should be based on the client's individual needs and lifestyle, and it is more important to change the appliance when necessary (e.g., when the pouch is full or when the skin barrier is no longer intact) rather than adhering to a specific time after meals.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Measure the client’s vital signs: The first priority after a fall is to assess the client's physical condition to determine if any immediate harm or injury has occurred. Taking the vital signs allows the nurse to assess for signs of shock, internal injury, or other complications that could require urgent intervention. This step should be done before notifying the provider or completing paperwork.
B) Notify the client's provider: While notifying the provider is important, it is not the first step. The nurse's priority is to assess the client’s condition and ensure they are stable. Once the client’s condition has been assessed, the provider can be notified if necessary.
C) Complete an incident report: An incident report should be completed after the client’s immediate needs are addressed. While documentation of the fall is important, the priority is the client’s safety and well-being. The nurse should first evaluate and stabilize the client before focusing on administrative tasks like the incident report.
D) Document the fall in the client's medical record: Although documentation is essential, the first priority should always be assessing and stabilizing the client. Once the client’s safety is ensured, then documenting the event and any findings is appropriate.
Correct Answer is C
Explanation
A) "You owe it to your mother to take care of her now that she needs you.":
This response is not supportive and places unnecessary guilt on the son. Caregiving for a loved one with Alzheimer's disease is demanding, and expecting the son to provide care without considering his own needs is unrealistic. Guilt-tripping him may lead to burnout, as it does not acknowledge the emotional and physical strain of caregiving.
B) "You should think about placing your mother in a long-term care facility.":
While this may be a viable option for some families, this statement does not acknowledge the son’s emotional struggle or immediate need for support. Suggesting a long-term care facility may be premature without exploring other options and may cause the son to feel as though he is being pushed into a decision he is not ready to make.
C) "Let me give you some information about respite care for your mother.":
This is the most appropriate response. Respite care provides temporary relief for family caregivers, allowing them time to rest and recharge. It is a supportive approach that acknowledges the son’s exhaustion and provides him with a helpful resource. Respite care can alleviate caregiver burnout and help maintain the quality of care for the client.
D) "I think you should find other family members who could help your mother.":
While involving other family members can be helpful, this response does not provide immediate support or acknowledge the son’s current feelings of exhaustion. Suggesting that he simply find other family members may come across as dismissive of his current emotional state and may not offer the practical help he needs at this moment.
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