The practical nurse (PN) is performing stoma care with a client. While cleaning around the stoma, the PN notices blood on the washcloth. Which action should the PN take next?
Place a pre-moistened dressing on the stomal site.
Apply firm pressure with a dry gauze to the stoma
Stop the stomal care and notify the healthcare provider.
Continue to clean around the skin surrounding the stomal site.
The Correct Answer is D
A. Place a pre-moistened dressing on the stomal site: Applying a dressing over the stoma without further assessment may interfere with visualization and proper cleaning, and it does not address the source of the minor bleeding observed during care.
B. Apply firm pressure with a dry gauze to the stoma: Applying pressure directly to the stoma can cause trauma and worsen bleeding. Gentle handling is essential, as minor oozing is common due to the stoma’s vascular nature.
C. Stop the stomal care and notify the healthcare provider: Notifying the provider is important if bleeding is significant or persistent, but minor bleeding from the stoma during routine care is usually expected. Immediate cessation is not necessary unless there is active hemorrhage.
D. Continue to clean around the skin surrounding the stomal site: Minor bleeding is common because the stoma tissue is highly vascular. The PN should proceed with gentle cleaning to maintain skin integrity and complete proper stoma care, documenting the observation and monitoring for any increase in bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1.0"]
Explanation
Identify the prescribed dose and the available concentration.
Prescribed dose = 5 mg
Available concentration = 10 mg per 2 mL
Calculate the volume in milliliters (mL) to administer.
Volume (mL) = (Prescribed dose (mg) / Available concentration (mg)) x Available volume (mL)
= (5 mg / 10 mg) x 2 mL
= 0.5 x 2 mL
= 1.0 mL.
Correct Answer is A
Explanation
A. That language is not allowed: Setting clear and firm boundaries in a calm, professional tone teaches the adolescent appropriate behavior while maintaining respect and therapeutic rapport. It helps the client understand acceptable communication without shaming or escalating the situation.
B. If you talk like that again, I will tell your parents: Threatening to report the behavior may provoke defiance or embarrassment rather than promote understanding. The goal is to correct the behavior through professional boundary setting, not intimidation.
C. The size of my breasts is of no concern to you: This response draws further attention to the inappropriate comment and may inadvertently encourage continued remarks, rather than redirecting the client appropriately.
D. Do you really think so?: Responding in this way reinforces the inappropriate comment and can be misinterpreted as encouragement, which undermines professional boundaries and the therapeutic nurse–client relationship.
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