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 C
Explanation
A. Stating that hospice care is the best option might not align with the client's wishes for continued treatment.
B. Encouraging the client to enjoy their time is supportive but doesn't address the client's request for more treatment.
C. Initiating a discussion with the healthcare provider allows the client to explore available treatment options while honoring their wishes.
D. Using phrases that emphasize the limited time left might not be supportive or respectful of the client's wishes for more treatment.
Correct Answer is B
Explanation
A. Delivering a series of high-pitched sounds at random intervals is not related to the Weber's test.
B. Weber's testis performed by striking the tuning fork and placing it against the middle of the forehead. Ask the patient if the tone is equal in both ears. Diminution in the affected ear indicates sensorineural hearing loss.
C. Placing an activated tuning fork on the client's mastoid process is not part of the Weber's test.
D. Whispering a series of words softly into one ear is unrelated to the Weber's test; it's a test for assessing auditory acuity.
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