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","C","E"]
Explanation
Choice A rationale:
While wearing a protective gown is essential to minimize exposure to bodily fluids and to ensure the nurse's protection, it is not specifically aimed at decreasing the risk for ventilator-associated pneumonia (VAP). The key interventions to prevent VAP focus on maintaining airway hygiene and proper positioning, not just personal protective equipment during suctioning.
Choice B rationale:
Monitoring oral secretions every 2 hours is an important strategy in reducing the risk of VAP. Accumulation of secretions in the mouth and upper airway can promote bacterial growth, increasing the risk of aspiration and infection. By regularly assessing and removing secretions, the nurse can reduce the chances of bacteria being aspirated into the lungs and causing pneumonia.
Choice C rationale:
Oral care every 2 hours is a critical intervention to reduce the risk of VAP. Mechanical ventilation predisposes clients to the growth of bacteria in the oral cavity, and poor oral hygiene increases the risk of oral bacteria being aspirated into the lungs. Regular oral care, including brushing teeth, gums, and the tongue, as well as using antiseptic solutions, helps reduce the microbial load in the mouth and decreases the risk of VAP.
Choice D rationale:
Maintaining a client in a supine position is not recommended for preventing VAP. The best practice is to maintain the head of the bed elevated at a 30-45 degree angle (semi-Fowler's position) to reduce the risk of aspiration. A supine position increases the likelihood of gastric contents or secretions being aspirated into the lungs, which can lead to VAP.
Choice E rationale:
Assessing the client daily for readiness for extubation is an essential practice in preventing VAP. The longer a patient remains intubated, the higher the risk of developing VAP due to prolonged exposure of the endotracheal tube in the airway. Regular assessment for extubation helps to ensure that the client is appropriately weaned off the ventilator as soon as they are stable, reducing the risk of VAP and other complications associated with prolonged ventilation.
Correct Answer is B
Explanation
Choice A rationale:
Is not a safe fall prevention strategy. Securing cords under carpeting can create tripping hazards. It is better to keep cords away from commonly used walking paths or use cord covers to prevent falls.
Choice B rationale:
Purchasing a skid-proof bathtub mat is a good fall-prevention strategy for an older adult client. It helps prevent slipping and falling in the bathroom, which is a common area for accidents in older adults.
Choice C rationale:
Is not a recommended fall prevention strategy. Leather soles can be slippery on smooth surfaces, increasing the risk of falls. Instead, the client should wear shoes with rubber soles that provide better traction.
Choice D rationale:
Is not the best option. Throw rugs, even with rubber backing, can still shift or bunch up, posing a tripping hazard. It's safer to avoid using throw rugs altogether or ensure they are firmly secured to the floor.
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