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. Involving the supervisor for a temporary password might not be necessary when other options for password recovery are available.
B. Asking another nurse to document on behalf of the newly licensed nurse might lead to issues related to accountability and accuracy.
C. Providing contact information for password recovery assistance is the most appropriate action.
D. Sharing passwords compromises security and violates policies and should be avoided.
Correct Answer is D
Explanation
A. Allowing space for three fingers is not a standard practice for tracheostomy ties. The ties should be snug but not overly tight, typically allowing for one or two fingers’ width to ensure proper fit and comfort.
B. A quick-release knot is not typically used for securing tracheostomy ties for safety reasons.
C. Extending the client's neck while securing the ties could cause discomfort and is not necessary.
D. This is the safest method to prevent accidental dislodgement of the tracheostomy tube. By securing the new ties first, the tracheostomy tube remains in place, reducing the risk of complications.
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