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
Rationale for A: Area rugs pose a significant tripping hazard for older adults, especially for those with osteoporosis who are at an increased risk for fractures if they fall. The nurse should intervene by advising the client to remove the area rug to prevent falls.
Rationale for B: Grab bars installed in the shower are a safety feature that helps prevent falls, especially for clients with mobility issues. This is a positive finding and does not require intervention.
Rationale for C: Storing prescriptions in a medication organizer helps the client keep track of their medications and prevents confusion, especially in older adults. This is an effective way to manage medications and does not need intervention.
Rationale for D: The hot water heater set to 47°C (117°F) is within the safe range to prevent burns while still providing sufficient warmth for bathing. This does not pose a risk to the client, and no intervention is needed.
Correct Answer is A
Explanation
A. Speech-language pathologists specialize in assessing and managing swallowing difficulties (dysphagia) after a stroke.
B. Social workers primarily address psychosocial aspects and may not directly manage swallowing difficulties.
C. Physical therapists focus more on mobility and physical rehabilitation.
D. Occupational therapists help with daily living activities but might not specialize in dysphagia management.
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