A nurse is caring for a patient with a colostomy. The ostomy drainage bag should be emptied whenever it is
full.
1/2 full
1/4 full.
3/4 full.
The Correct Answer is B
The correct answer is Choice B.
Choice A rationale: Waiting until the ostomy drainage bag is full increases the risk of leakage and can put undue pressure on the stoma, leading to potential skin irritation or damage. Regular emptying is crucial for maintaining stoma health and preventing complications.
Choice B rationale: Emptying the ostomy drainage bag when it is 1/2 full is recommended to prevent leaks and reduce pressure on the stoma. This practice helps maintain skin integrity around the stoma and ensures the drainage bag functions effectively.
Choice C rationale: Emptying the ostomy drainage bag when it is only 1/4 full may be too frequent and unnecessary, leading to increased use of supplies and potential irritation from frequent manipulation. It is more practical to aim for 1/2 full for routine care.
Choice D rationale: Waiting until the ostomy drainage bag is 3/4 full increases the risk of leakage and pressure on the stoma, similar to waiting until it is full. It is essential to empty the bag more regularly to maintain optimal stoma health and prevent issues
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A This change in blood pressure is not alarming and does not require immediate cessation of the procedure.
Choice B A slight increase in temperature is within a normal range and does not indicate an urgent issue related to the stool removal procedure.
Choice C A significant decrease in pulse rate suggests bradycardia, which can be a serious sign and might be caused by the stimulation of the vagus nerve during the procedure. The nurse should stop immediately and take corrective action.
Choice D An increase in respiratory rate may indicate increased anxiety or discomfort, but it is not an immediate cause for stopping the procedure.
Correct Answer is C
Explanation
Choice A Using a cool solution might cause discomfort and could lead to cramping, which is not ideal for an enema administration.
Choice B Boiling the solution is unnecessary and might be unsafe, as it could cause burns or damage the components of the enema.
Choice C Warming the solution to body temperature (around 98.6°F or 37°C) is the appropriate approach, as it ensures patient comfort and reduces the risk of cramping or discomfort.
Choice D Microwaving the solution might lead to uneven heating and could potentially create hot spots, which could cause burns or discomfort for the patient.
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