Which skill does the nurse teach a patient with a new colostomy before discharge from the health care facility? (Select all that Apply)

How to open and close the pouch

How to determine whether the ostomy is healing appropriately

How to irrigate the colostomy

How to change the pouch

How to empty the pouch

Answer and Explanation

Correct Answer : A,B,D,E

A. How to open and close the pouch: The patient must be able to manage their pouch independently. This skill helps them maintain hygiene and prevent leakage.

B. How to determine whether the ostomy is healing appropriately: Patients should be educated on signs of infection, irritation, or necrosis around the stoma.

C. How to irrigate the colostomy: Not taught initially because irrigation is only necessary for some patients and is usually introduced later. It’s mainly for descending or sigmoid colostomies, not all types.

D. How to change the pouch: A crucial skill to prevent leakage and skin irritation.

E. How to empty the pouch: Patients should know when and how to empty it to maintain cleanliness and avoid leaks.

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Correct Answer is D

Explanation

A. Chew the sucralfate thoroughly before swallowing. Sucralfate should be swallowed whole or dissolved in water, not chewed.

B. Take sucralfate with a full glass of milk. Milk can interfere with the medication’s effectiveness.

C. Take an antacid with sucralfate. Antacids should be taken separately to avoid interaction.

D. Allow a 2-hour interval between these medications. Sucralfate can interfere with phenytoin absorption, so they should be spaced apart.

A. Functional urinary incontinence B. Urinary retention C. Urge urinary incontinence D. Impaired skin integrity

Correct Answer is C

Explanation

A. Functional urinary incontinence: This occurs when mobility or cognitive impairments prevent the client from reaching the toilet in time. Since this client has a strong urge to void, functional incontinence is not the best fit.

B. Urinary retention: Urinary retention is the inability to empty the bladder completely, often leading to overflow incontinence. However, this client experiences urgency and leakage, not retention.

C. Urge urinary incontinence: This occurs when a strong, sudden urge to urinate leads to involuntary leakage before reaching the toilet. It is often due to overactive bladder or neurological issues.

D. Impaired skin integrity: While prolonged incontinence can lead to skin breakdown, the primary diagnosis should address the cause of incontinence rather than a secondary complication.

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Which skill does the nurse teach a patient with a new colostomy before discharge from the health care facility? (Select all that Apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who takes phenytoin and has a new prescription for sucralfate tablets. Which of the following instructions should the nurse include?

Correct Answer is D

Explanation

An 85-year-old client is experiencing uncontrollable leakage of urine with a strong desire to void and even leaks on the way to the toilet. Which priority nursing diagnosis will the nurse include in the client's plan of care?

Correct Answer is C

Explanation

A nurse is planning care for a group of patients. Which task will the nurse assign to the nursing assistive personnel (AP)?

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