A nurse is completing discharge teaching about ostomy care with a client who has a new stoma. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

"Use povidone-iodine to clean around the stoma."

"Cut the opening of the pouch / of an inch larger than the stoma."

"Empty the ostomy pouch when it becomes one-third full of contents."

"Place a piece of gauze over the stoma while changing the pouch."

"Expect the stoma to turn a purple-blue color as it heals."

Answer and Explanation

Correct Answer : B,C,D

A.   Povidone-iodine is not recommended for cleaning around the stoma as it may cause irritation.
B.   Ensuring the pouch opening is slightly larger than the stoma helps prevent irritation and ensures proper fit.
C.   Regular emptying of the ostomy pouch prevents leakage and skin irritation. It also prevents it from becoming too heavy and pulling away from the skin.
D.   The nurse should advise the client to place a piece of gauze over the stoma while changing the pouch to protect it from injury and contamination.
E.   A purplish-blue change in the stoma is an indication of impaired blood supply to the stoma and should be promptly reported to the healthcare provider.

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Correct Answer is D

Explanation

A. This represents a situational loss, as it is related to external circumstances such as economic changes.
B. This also represents a situational loss, as it involves the loss of material possessions.
C. This is a situational loss, specifically a loss of a loved one, which is different from a maturational loss.It is unexpected andoccurs due to an external event or situation.
D. This is an example of a maturational loss, as it involves a normal life transition that brings about feelings of loss and adjustment.

A. Release the skin before withdrawing the needle. B. Insert at a 45° angle. C. Withdraw the needle quickly. D. Pull the skin laterally.

Correct Answer is D

Explanation

A. With the Z-track method, the skin is pulled laterally or to the side before the needle is inserted and released after the injection is administered to ensure the medication remains within the muscle and does not leak into the subcutaneous tissue.
B. The angle of insertion for intramuscular injections can vary depending on factors such as the client's body habitus and the length of the needle but is typically 90 degrees.
C. The needle should be withdrawn slowly and steadily to minimize tissue trauma and prevent medication leakage.
D. The Z-track method involves pulling the skin laterally or to the side before inserting the needle to create a zigzag pathway for the medication. This helps seal the needle track after the injection, reducing the risk of medication leakage into subcutaneous tissues.

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A nurse is completing discharge teaching about ostomy care with a client who has a new stoma. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

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