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.
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Related Questions
Correct Answer is C
Explanation
A. Starting a blood transfusion without obtaining consent is a violation but may fall more under the category of battery than negligence.
B. Preventing a client from leaving the facility might relate more to issues of false imprisonment or breach of autonomy rather than negligence.
C. Administering medication without properly identifying the client can be considered negligence as it breaches the standard duty of care.
D. Discussing client care in a public area with visitors present might breach confidentiality but might not be categorized as negligence unless sensitive or protected information was disclosed.
Correct Answer is C
Explanation
A. Use an 18-gauge, 1-inch needle to administer the medication:
This is incorrect because an 18-gauge needle is too large and not appropriate for subcutaneous injections like heparin. A smaller gauge needle, such as 25- to 27-gauge, and a shorter length (⅜ to ⅝ inch) is recommended for subcutaneous injections.
B. Massage the injection site after withdrawing the needle:
This is incorrect because massaging the injection site after administering heparin can increase the risk of bruising and hematoma formation. Heparin is an anticoagulant, and gentle handling of the injection site is crucial.
C. Inject 5.1 cm (2 in) away from the umbilicus:
This is correct. Heparin is administered subcutaneously, typically in the abdomen, avoiding areas near the umbilicus or scars. Injecting at least 2 inches away from the umbilicus ensures the medication is delivered to appropriate subcutaneous tissue and minimizes complications.
D. Expel air bubble before injecting medication:
This is incorrect because the air bubble in prefilled heparin syringes should not be expelled. The air bubble helps ensure the full dose is administered and reduces the risk of medication leakage.
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