What should a nurse instruct the patient to do to ensure a good fit of the appliance to avoid leakage?
Confirm that the pouch covers the entire abdomen.
Place the pouch only when lying down.
Confirm that the pouch fits tightly to the edges of the stoma
Check pouch placement to ensure a firm seal.
The Correct Answer is D
Rationale:
A. Confirm that the pouch covers the entire abdomen is incorrect because the pouch only needs to cover the stoma and adhere securely to the surrounding skin. Covering the entire abdomen is unnecessary and impractical.
B. Place the pouch only when lying down is incorrect because appliance placement is usually best done while standing or sitting to account for natural skin folds and movement, which helps achieve a better seal.
C. Confirm that the pouch fits tightly to the edges of the stoma is incorrect because the opening should fit closely but not tightly against the stoma. A pouch that is too tight can cause irritation, pressure, or impaired blood flow to the stoma.
D. Check pouch placement to ensure a firm seal is correct because ensuring a secure seal between the skin barrier and the peristomal skin is essential to prevent leakage and protect the skin from irritation and breakdown.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D"]
Explanation
Rationale:
A. White blood cell count: The white blood cell count decreased from 5,500/mm³ (within normal range) to 4,500/mm³ (below the reference range). This reflects chemotherapy-induced myelosuppression rather than improvement and increases infection risk.
B. Platelet count: The platelet count declined from 150,000/mm³ (lower limit of normal) to 140,000/mm³ (below normal). This indicates worsening thrombocytopenia, not improvement.
C. Bleeding episodes: The client reports fewer bleeding episodes after switching to a soft-bristled toothbrush. Reduced bleeding suggests improved symptom management and safer self-care behaviors, indicating improvement.
D. Oral health: Improved oral care practices and reduced gum bleeding reflect better oral health, which is a positive outcome during chemotherapy and indicates improvement.
E. Weight change: The client experienced weight loss (70.5 kg to 69 kg). Unintentional weight loss during chemotherapy does not indicate improvement and may suggest nutritional compromise.
Correct Answer is D
Explanation
Rationale:
A. ERCP is a procedure used to diagnose and treat disorders of the bile ducts, pancreas, and gallbladder. It is not used for screening for rectal or colorectal cancer.
B. Upper GI endoscopy examines the esophagus, stomach, and duodenum, not the colon or rectum. It is used for conditions such as ulcers, gastritis, or esophageal cancer, so it is not appropriate for rectal cancer screening.
C. An upper GI series is a radiographic examination of the upper digestive tract using contrast (barium) to evaluate the esophagus, stomach, and duodenum. It does not assess the rectum or colon.
D. A colonoscopy is the primary screening tool for rectal and colorectal cancer. It allows direct visualization of the entire colon and rectum, detection of polyps or tumors, and the ability to perform biopsies or remove polyps during the procedure. Colonoscopy is recommended for average-risk adults starting at age 45–50 and at earlier ages for those with risk factors such as family history or genetic predisposition.
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