A nurse is caring for a client who has a colostomy. Which of the following actions should the nurse take?
Rub the peristomal skin dry after cleaning.
Change the pouch once every 24 hr.
Ensure the pouch is 0.32 cm (1/8 in) larger than the stoma.
Apply the pouch while the skin barrier is still damp.
The Correct Answer is C
A. Rather than rubbing dry, patting the peristomal skin dry after cleaning is recommended.
B. The frequency of changing the pouch depends on various factors, not a fixed 24-hour schedule.
C. Ensuring the pouch is slightly larger than the stoma prevents irritation and damage.
D. Applying the pouch when the skin barrier is dry ensures better adhesion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Eyelashes that curl slightly outward is a normal finding.
B. An involuntary blink rate of 30 to 35 times per minute might be within the normal range but is not typically assessed during a routine eye examination.
C. Pupils of 8 to 9 mm in diameter might indicate dilation, which is not a normal finding during a regular eye assessment.
D. Corneas with an opaque appearance could indicate issues such as corneal edema or opacity, which are abnormal findings.
Correct Answer is C
Explanation
A. Weighing oneself once weekly may not be frequent enough to monitor changes related to heart failure or medication effects.
B. Taking hydrochlorothiazide in the evening is not usually a crucial safety consideration; it is typically taken in the morning due to its diuretic effects.
C. Leaving a light on in the bathroom at night can prevent falls, which are a significant concern in older adults with heart failure.
D. Taking a hot bath before bedtime might not be a safety consideration related to heart failure or medication use and could potentially cause issues with temperature regulation or dehydration.
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