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 C
Explanation
A. Expressing a desire for independence indicates the client may not have fully adapted to relying on others yet.
B. Reluctance to ask for help suggests the client is still adjusting and may not have fully embraced the new living arrangement.
C. Expressing enjoyment or appreciation for others cooking for them indicates acceptance of assistance and adaptation to the new living situation.
D. Expressing uncertainty about daily activities suggests a lack of adjustment to the new environment and situation.
Correct Answer is A
Explanation
A: The presence of an area rug over a tile floor poses a tripping hazard, which is particularly dangerous for individuals with osteoporosis due to the increased risk of fractures from falls. The rug can easily slip or edges can curl, leading to potential accidents. Therefore, it is crucial for the nurse to address this issue to prevent falls.
B: Grab bars in the shower are a safety feature that assists individuals in maintaining balance and preventing slips, which is beneficial for a person with osteoporosis. There is no need for intervention as this is a recommended safety measure.
C: Storing prescriptions in a medication organizer is a good practice as it helps ensure that medications are taken correctly and on time. This is especially important for older adults who may have multiple prescriptions. Thus, no intervention is needed here.
D: Setting the hot water heater to 47° C (117° F) can pose a risk of burns, especially for older adults whose skin may be more sensitive and who may have a delayed reaction to withdraw from hot surfaces. However, this is not directly related to osteoporosis, and while it is a safety concern, it is not as immediately hazardous as a tripping risk.
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