A patient with a colostomy continues to worry about odor. What instruction should a nurse provide to allay this concern?
Pierce the top of the appliance bag with a pin to allow gas to escape.
Wear tight-fitting underwear.
Rinse the pouch in a vinegar solution.
Improve personal hygiene.
The Correct Answer is D
Rationale:
A. Piercing the colostomy pouch is dangerous and can lead to leakage, contamination, and infection. It also defeats the purpose of the pouch, which is to contain waste and control odor. Modern pouches often have built-in filters to safely release gas without allowing odor to escape.
B. Tight-fitting underwear does not prevent odor. Instead, it can trap gas and moisture, potentially increasing odor and causing skin irritation or breakdown around the stoma. Properly fitting undergarments are important for comfort but are not effective for odor control.
C. While older methods suggested rinsing pouches with vinegar, this is unnecessary with modern disposable or closed-system pouches. Improper rinsing can compromise the pouch seal, reduce its effectiveness, and irritate the skin.
D. Maintaining proper hygiene around the stoma is the safest and most effective way to control odor. This includes regularly emptying the pouch before it becomes too full, gently cleaning the peristomal skin, changing the pouch as needed to prevent leaks and bacterial growth, and using deodorizing drops or odor-filter pouches if recommended. Proper hygiene reduces bacterial growth, minimizes odor, prevents skin irritation, and helps alleviate patient anxiety, improving quality of life.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Mild fatigue is common in many patients, especially those undergoing cancer treatment, and is not immediately life-threatening. While it should be monitored, it does not require urgent reporting to the next shift.
B. Nausea and vomiting are expected side effects of many treatments, including chemotherapy. They should be managed symptomatically, but in the absence of severe dehydration or inability to tolerate fluids, they are not considered urgent for shift-to-shift reporting.
C. Fever and chills in a patient, particularly one with neutropenia or immunosuppression, may indicate a serious infection. In these patients, infections can progress rapidly and become life-threatening, so this must be reported immediately to ensure prompt intervention, including assessment, blood cultures, and possible initiation of antibiotics.
D. Dry, itchy skin is a common, non-urgent side effect of cancer treatments or environmental factors. While it should be addressed to maintain comfort and skin integrity, it does not require urgent reporting.
Correct Answer is C
Explanation
Rationale:
A. Removing the catheter without first aspirating the vesicant allows the drug to remain in the tissue, increasing the risk of severe local tissue necrosis. This is not the recommended first action.
B. Some vesicant extravasations do require antidote administration, but the antidote is not always given through the IV line itself and typically after the solution is aspirated. Administering through the IV without removing the drug from the tissue first can worsen tissue injury.
C. The priority action is to stop the infusion and carefully aspirate any residual vesicant from the catheter before removing it. This minimizes the amount of vesicant that enters surrounding tissue, reducing necrosis, blistering, and long-term damage. After aspiration, the nurse follows facility protocol for antidote administration, compression (warm or cold depending on the drug), and site monitoring.
D. While elevation and warm or cold compresses are part of post-extravasation care, they are secondary interventions. The priority is to stop the infusion and remove as much vesicant as possible to prevent further tissue injury.
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