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
Explanation
Rationale for A: Side-lying with the right side of the chest elevated does not provide the necessary gravitational effect to drain the left lower lobe. The Trendelenburg position is more effective for lower lobe drainage.
Rationale for B: Right lateral in Trendelenburg position is the appropriate position for postural drainage of the left lower lobe. The combination of gravity and positioning helps drain secretions from the lower lobe effectively.
Rationale for C: Prone with pillows under the lower extremities does not facilitate proper drainage of the left lower lobe. This position might be more useful for posterior lobe drainage, not the lower lobes.
Rationale for D: Supine in low-Fowler's position is not ideal for draining secretions from the lower lobes of the lungs. Postural drainage requires specific positions that use gravity to promote secretion clearance from the affected lobe.
Correct Answer is B
Explanation
A. Respiratory rate is part of vital signs assessment but is not typically included in anthropometric measurements.
B. Weight is a key component of anthropometric assessment, measuring body mass or body weight.
C. Level of orientation pertains to the client's mental status and cognitive functioning, not part of anthropometric measurements.
D. Current pain level is important but not directly related to anthropometric measurements.
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