A nurse is caring for a client who has a new colostomy. Which of the following statements should the nurse include in educating the client regarding colostomy care?

"Cut the opening on the skin barrier wafer to customize fit over the stoma.".

"Empty the bag when it is three-fourths full of stool.".

"The color of the stoma should be slightly purple.".

"Cleanse the peristomal skin with moisturizing soap and water.".

Answer and Explanation

The Correct Answer is A

Choice A rationale:
Properly cutting the opening on the skin barrier wafer to fit over the stoma is crucial to prevent any irritation or damage to the surrounding skin. A well-fitted wafer creates a seal around the stoma, reducing the risk of stool coming into contact with the skin, which can cause excoriation.
Choice B rationale:
Emptying the bag when it is three-fourths full of stool is unrelated to the education on colostomy care. This information was provided in the previous question () and is not relevant to colostomy care education.
Choice C rationale:
The color of the stoma should not be slightly purple. A healthy stoma should be pink or red, indicating a good blood supply. A purple or dark-colored stoma could indicate inadequate blood flow, which is a concern and requires immediate medical attention.
Choice D rationale:
Cleansing the peristomal skin with moisturizing soap and water is not the recommended approach. The nurse should use plain water or mild, non-moisturizing soap to clean the peristomal skin, as moisturizing soap may leave a residue that affects the adhesion of the skin barrier wafer.

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Correct Answer is C

Explanation

Choice A rationale:
Having the client point their chin upward to swallow is not a recommended action to reduce the risk of aspiration. In fact, this action can increase the risk of choking and aspiration, as it may cause food or liquids to enter the airway.
Choice B rationale:
Offering the client saltine crackers between meals is not a suitable action for reducing the risk of aspiration. Saltine crackers are dry and can be challenging to swallow for someone with dysphagia, potentially increasing the risk of aspiration.
Choice C rationale:
Thicken liquids before serving is the correct action to reduce the risk of aspiration in a client with dysphagia. Thickened liquids are easier to swallow and less likely to enter the airway, reducing the risk of aspiration pneumonia.
Choice D rationale:
Placing food on the affected side of the mouth does not address the risk of aspiration directly. Dysphagia may affect both sides of the mouth, and placing food on one side does not ensure safe swallowing and reduces the effectiveness of addressing the problem.

A. Administer morphine intermittent IV bolus every 2 hr to the client. B. Turn the client from side to side every 4 hr. C. Provide the client with nasotracheal suctioning for 15 to 20 seconds at a time. D. Instruct the client to hold the inhaled breath for 2 to 5 seconds with incentive spirometer use.

Correct Answer is D

Explanation

Choice A rationale:

Administering morphine intermittent IV bolus every 2 hours is not a suitable intervention for reducing the risk of atelectasis. While pain management is important postoperatively, morphine can depress respiratory function and increase the risk of atelectasis.

Choice B rationale:

Turning the client from side to side every 4 hours is important for preventing pressure ulcers and promoting comfort, but it is not a specific intervention for reducing the risk of atelectasis.

Choice C rationale:

Providing nasotracheal suctioning for 15 to 20 seconds at a time is not a preventive measure for atelectasis. Suctioning may be necessary for airway clearance in certain situations, but it does not address the root cause of atelectasis.

Choice D rationale:

This is the correct choice. Instructing the client to hold the inhaled breath for 2 to 5 seconds with incentive spirometer use is an effective intervention to reduce the risk of atelectasis. Incentive spirometry helps to expand the lungs and improve ventilation, preventing atelectasis after surgery.

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A nurse is caring for a client who has a new colostomy. Which of the following statements should the nurse include in educating the client regarding colostomy care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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