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. Directing question involves directing the conversation toward a specific topic or answer.
B. Reflective question involves restating or reflecting the client's words to encourage further communication and exploration of feelings.
C. Sequencing question involves organizing the client's story in chronological order.
D. Disconfirming question involves challenging or denying the client's statements.
Correct Answer is D
Explanation
A. Black, tarry stools may indicate gastrointestinal bleeding but are not associated with abdominal cramping and frequent bowel movements.
B. Dry, odorous stools are not typical findings in a client experiencing abdominal cramping and frequent bowel movements.
C. Hard, formed stools are not consistent with the symptoms described by the client.
D. Loose, watery stools are indicative of frequent bowel movements and may be associated with abdominal cramping.
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