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 A

Explanation

Answer: A

Rationale:

A) Place the client in a room with negative airflow: Disseminated herpes zoster (shingles) requires airborne precautions because the virus can become aerosolized. A room with negative airflow helps prevent the spread of the virus to other areas, protecting healthcare workers and other patients from infection.

B) Remove isolation gown after leaving the client's room: Isolation gowns should be removed before leaving the client's room to prevent the spread of contaminants to other areas. This intervention is important for infection control but is not specific to the requirement for negative airflow in cases of disseminated herpes zoster.

C) Apply ketoconazole to the lesions three times per day: Ketoconazole is an antifungal medication and is not used for treating herpes zoster, which is caused by a viral infection. Antiviral medications, such as acyclovir, are appropriate for treating herpes zoster lesions.

D) Provide the client with eye protection for ultraviolet B light therapy: Eye protection is necessary during UVB light therapy to protect the eyes, but UVB light therapy is not a standard treatment for disseminated herpes zoster. The priority intervention is to prevent the spread of the infection by using a negative airflow room.

A. Maintain affected leg elevated on several pillows. B. Instruct the client to wiggle the toes once every 4 hr. C. Use a hair dryer to promote drying of the cast. D. Apply heat to the client's cast to provide pain relief.

Correct Answer is A

Explanation

Choice A rationale:

The nurse should maintain the affected leg elevated on several pillows to reduce swelling and promote venous return. Elevating the leg helps minimize edema, which can be beneficial for the healing process and overall comfort of the client.

Choice B rationale:

Instructing the client to wiggle the toes once every 4 hours is not necessary and may cause discomfort to the fractured tibia. Toe wiggling does not provide any significant benefit in this context and could potentially disrupt the healing process.

Choice C rationale:

Using a hair dryer to promote drying of the cast is not recommended. Applying heat to the fiberglass cast may alter its integrity and lead to uneven drying, potentially weakening the cast's support.

Choice D rationale:

Applying heat to the client's cast for pain relief is not advisable. Heat may also weaken the cast material and is unlikely to provide effective pain relief for a fractured tibia. Instead, the nurse should follow the prescribed pain management plan and use appropriate pain medications as ordered by the healthcare provider.

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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

A nurse is planning care for a client who has disseminated herpes zoster (shingles). Which of the following interventions should the nurse include?

Correct Answer is A

Explanation

A nurse is caring for a client who had a fiberglass cast applied 30 min ago for a fractured tibia. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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