A patient says. "I hate this yucky paste under my appliance. I think I will just tape it on." What is the best response by the nurse?
"Taping will not seal the wafer tight enough to prevent leakage or fill increases."
"Taping will not work?"
"Taping with waterproof tape is just as effective as the paste."
"Taping is far more irritating to the skin than the paste would be."
The Correct Answer is A
Rationale:
A. The paste under a colostomy or ileostomy appliance creates a seal between the stoma and the wafer, preventing leakage of effluent onto the skin. Simply taping the wafer may not provide an adequate seal, increasing the risk of leakage, skin irritation, and infection. This response educates the patient on the functional importance of the paste.
B. This response is vague and non-informative, and does not explain why the paste is necessary or the risks of not using it. It fails to address the patient’s concern.
C. This is incorrect. Waterproof tape alone does not conform to the stoma or fill uneven skin surfaces, so it cannot replace the sealant paste, increasing the likelihood of leakage and skin breakdown.
D. While tape can irritate the skin, the main concern is seal integrity and prevention of leakage, not just skin irritation. This explanation does not fully address the functional reason for using paste.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Confirm that the pouch covers the entire abdomen is incorrect because the pouch only needs to cover the stoma and adhere securely to the surrounding skin. Covering the entire abdomen is unnecessary and impractical.
B. Place the pouch only when lying down is incorrect because appliance placement is usually best done while standing or sitting to account for natural skin folds and movement, which helps achieve a better seal.
C. Confirm that the pouch fits tightly to the edges of the stoma is incorrect because the opening should fit closely but not tightly against the stoma. A pouch that is too tight can cause irritation, pressure, or impaired blood flow to the stoma.
D. Check pouch placement to ensure a firm seal is correct because ensuring a secure seal between the skin barrier and the peristomal skin is essential to prevent leakage and protect the skin from irritation and breakdown.
Correct Answer is C
Explanation
Rationale:
A. Hair loss is a common and visible side effect of many anti-neoplastic drugs, but it is not life-threatening. While it can affect self-esteem and quality of life, it does not endanger the patient’s health.
B. Electrolyte imbalances can occur due to chemotherapy, vomiting, or tumor lysis syndrome, and they require monitoring and correction. However, they are usually manageable with fluids and medications and are not the primary life-threatening risk of anti-neoplastic therapy.
C. Bone marrow suppression (myelosuppression) is the most dangerous side effect of anti-neoplastic drugs because it reduces the production of white blood cells, increasing the risk of infection; red blood cells, causing anemia and decreased oxygen delivery; and platelets, increasing the risk of bleeding. Severe myelosuppression can result in life-threatening infections, hemorrhage, or hypoxia, making it the most critical adverse effect to monitor and manage.
D. Although common and distressing, nausea and vomiting are generally manageable with modern antiemetics and are rarely directly life-threatening.
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