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.".
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Papilledema refers to swelling of the optic disc in the eye, which can occur due to increased intracranial pressure. While it may be present in cases of basilar skull fracture, it is not a reliable finding for determining the discharge of cerebrospinal fluid (CSF).
Choice B rationale:
The halo sign is a reliable finding for determining that the nasal discharge is cerebrospinal fluid. The halo sign is characterized by a ring of blood surrounded by a clear or yellowish fluid (CSF) on a dressing or tissue. This occurs because blood from the fracture mixes with the clear CSF, creating a distinct appearance.
Choice C rationale:
Racoon's eyes, also known as periorbital ecchymosis, is a term used to describe bruising around the eyes. While it can be seen in basilar skull fractures, it is not specific to cerebrospinal fluid leakage and, therefore, not reliable for identifying the nasal discharge as CSF.
Choice D rationale:
Elevated white blood cells (WBCs) in the nasal discharge can indicate infection, inflammation, or an immune response. However, it does not provide direct evidence that the discharge is cerebrospinal fluid, so this is not a reliable finding for determining the nature of the nasal discharge in this context.
Correct Answer is C
Explanation
Choice A rationale:
Notifying the surgeon of the temperature elevation is important, but it is not the nurse's priority. A temperature elevation after abdominal surgery could be a sign of infection, but the immediate action should be to assess the surgical incision for any signs of infection.
Choice B rationale:
Encouraging the client to drink more fluids is a good practice to maintain hydration and promote recovery after surgery. However, it is not the nurse's priority in this situation. The elevated temperature and potential infection take precedence over increasing fluid intake.
Choice C rationale:
This is the correct answer because the nurse's priority is to assess the surgical incision for signs of infection. An elevated temperature is a significant finding after surgery, and it may indicate a surgical site infection, which requires prompt assessment and intervention.
Choice D rationale:
Monitoring vital signs every 4 hours is an essential nursing intervention after surgery, but it is not the priority when the client has an elevated temperature and a recent surgical incision.
The nurse must first assess for signs of infection before proceeding with routine vital sign monitoring.
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