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 ["B","C","E"]
Explanation
A. At the end of the shift is incorrect. Medication verification is done before administration, not at the end of the shift.
B. When removing the medication from the medication drawer is correct. This is the first check to ensure the correct medication is selected.
C. Directly before administering the medication is correct. This is the final check to verify that the correct medication, dose, route, and time match the prescription before giving it to the client.
D. When reconciling counts of controlled substances is incorrect. While controlled substances require counting and verification, this is separate from the three medication checks performed during administration.
E. When preparing the medication dosage is correct. This is the second check, ensuring that the correct medication and dose are prepared accurately before administration.
Correct Answer is A
Explanation
A. Anaphylactic reactions can cause a sudden and severe drop in blood pressure, which is a potentially life-threatening symptom. It's a hallmark sign of anaphylaxis.
B. A feeling of swelling in the feet might indicate a localized reaction but is less specific to anaphylaxis.
C. Pain at the injection site might occur due to local irritation but isn't typically a primary sign of an anaphylactic reaction.
D. A sudden decrease in heart rate is not a typical sign of an anaphylactic reaction.
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