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.
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Related Questions
Correct Answer is D
Explanation
A. Sterile gloves, not clean gloves, should be worn when cleaning the inner cannula to reduce the risk of introducing infection into the tracheostomy site, which is a direct pathway to the airway.
B. Placing gauze pads under the flanges of the tracheostomy tube isn't a standard practice for tracheostomy care.
C. Cleansing the skin around the stoma with full-strength hydrogen peroxide can be too harsh and irritating to the skin.
D. Using a tracheostomy collar with hook-and-loop fasteners is a safe and effective way to secure the tracheostomy tube, ensuring it remains in place while minimizing the risk of skin breakdown and irritation. This method also allows for easier adjustment and replacement of the collar.
Correct Answer is B
Explanation
A: The width of the BP cuff should actually be 40% of the client's upper arm circumference, not 50%. Using a cuff that's too large can result in a falsely low reading, while a cuff that's too small can cause a falsely high reading.
B: It is important to recheck the BP in the other arm to compare readings. Differences in blood pressure between arms can indicate vascular issues and provide valuable diagnostic information. Consistency in readings is crucial for accurate diagnosis and treatment.
C: While it may be necessary to monitor the client's BP over time, immediately requesting another nurse to check the BP does not address the immediate concern of the accuracy of the initial reading.
D: Repositioning the client supine may be appropriate if orthostatic hypotension is suspected, but it is not the first action to take. The initial step should be to confirm the accuracy of the reading by checking the other arm.
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