The client is complaining of soreness around the stoma site. The nurse notes proper drainage in the bag, however, the surrounding skin is red, irritated, and moist. How will the nurse interpret this assessment?
This is normal with all new ostomies and the client needs educated on healing.
There is a leak in the appliance and the skin barrier will need replaced.
The ostomy is no longer functioning appropriately, the MD should be called.
The client is overhydrated causing watery stools.
The Correct Answer is B
A. Soreness and redness may occur with new ostomies, but persistent irritation may indicate a problem.
B. Red, irritated, and moist skin around the stoma site suggests a leak in the appliance, and the skin barrier needs replacing.
C. The assessment does not suggest a malfunction in ostomy function but rather a skin integrity issue.
D. Overhydration is not typically associated with skin irritation around the stoma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Expiratory stridor is associated with airway obstruction and is not typically related to heart failure.
B. Crackles (rales) in the lower lobes are often indicative of fluid accumulation and pulmonary congestion, common in heart failure.
C. Bruit over the aorta is a vascular sound and is not directly related to lung sounds or heart failure.
D. Inspiratory wheezes are associated with airway obstruction, not typically seen in heart failure; crackles are more relevant in this context.
Correct Answer is C
Explanation
A. While a fall-risk patient is important, the patient is currently sleeping and has a bed alarm in place, reducing immediate risk.
B. Pain management is important, but the patient is not in immediate distress, and pain can be addressed after the more critical patient is attended to.
C. A patient with a tracheostomy experiencing wheezing and increased secretions may be at risk for airway compromise and need immediate attention.
D. Turning a patient with a pressure ulcer, while important for prevention, is not as urgent as addressing potential airway issues in the tracheostomy patient.
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