The nurse is teaching a patient with a new ostomy about skin care to preserve tissue integrity. What teaching will the nurse provide about cleansing the ostomy area?

Use a whirlpool bath.

Use water and mild soap.

Use alcohol-based sanitizer.

Use chlorhexidine or HCG.

Answer and Explanation

The Correct Answer is B

The correct answer is choice B, Use water and mild soap.

When teaching a patient about ostomy care, the nurse should instruct the patient to clean the area around the ostomy with water and mild soap. Using a whirlpool bath, alcohol-based sanitizer, or chlorhexidine or HCG is not recommended as they can irritate the skin and damage the stoma. Cleansing the ostomy area with water and mild soap is the best way to maintain the skin's integrity and prevent irritation and infection.

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Correct Answer is C

Explanation

The correct answer is choice C, Place all 4 side rails up to prevent the patient from getting out of bed and falling.

When considering alternatives to restraints for a confused and agitated patient who is at high risk for falls, placing all 4 side rails up to prevent the patient from getting out of bed and falling is not an appropriate alternative. This action can be considered as restraint use and can increase the patient's agitation and risk for injury. Instead, the nurse should provide the patient with activities to do while in bed, play music or video selections of the patient's choice, and reduce stimulation noise and light to calm the patient.

A. Ask the client which language they would like the written materials. B. Ensure the client has access to all corrective eyewear. C. Speak in a loud voice directly at the patient. D. Place client close to the nurse's station. E. None F. None

Correct Answer is B

Explanation

A. Ask the client which language they would like the written materials.While providing written materials in the client’s preferred language is important for communication, this does not directly address the client's vision loss. It may help with understanding but does not enhance their ability to see the materials.

B. Ensure the client has access to all corrective eyewear.This is the most appropriate intervention. Ensuring that the client has access to corrective eyewear, such as glasses or contact lenses, will help maximize their remaining vision. This is a practical and supportive action for someone with moderate vision loss.

C. Speak in a loud voice directly at the patient.Vision loss does not imply hearing impairment, so speaking in a loud voice is unnecessary and could be confusing or frustrating for the client. Communication should be clear and normal in volume, not assuming a hearing deficit.

D. Place the client close to the nurse's station.Placing the client close to the nurse’s station may enhance safety and allow for quicker assistance. However, it is not specifically related to addressing the client's vision loss and may not be necessary depending on their overall condition.

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The nurse is teaching a patient with a new ostomy about skin care to preserve tissue integrity. What teaching will the nurse provide about cleansing the ostomy area?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The nurse is caring for a client with moderate vision loss. Which intervention would be most appropriate for this client?

Correct Answer is B

Explanation

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