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.)

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

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

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

"Cut the opening of the pouch 1/8 of an inch larger than the stoma."

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

Answer and Explanation

Correct Answer : A,D

Rationale

A. "Empty the ostomy pouch when it becomes one-third full of contents.": Emptying the pouch before it becomes too full prevents leakage, skin irritation, and discomfort. Regular emptying supports hygiene and maintains appliance adherence, which is essential for stoma care.

B. "Expect the stoma to turn a purple-blue color as it heals.": A healthy stoma should be pink to red, indicating good perfusion. Purple-blue discoloration may indicate ischemia or compromised blood flow, which requires immediate provider notification.

C. "Place a piece of gauze over the stoma while changing the pouch.": Gauze is not necessary and may interfere with proper pouch application. Direct handling with clean technique and using the appliance as designed is sufficient for maintaining hygiene and protecting the stoma.

D. "Cut the opening of the pouch 1/8 of an inch larger than the stoma.": Ensuring the pouch opening is slightly larger than the stoma protects peristomal skin from contact with effluent while maintaining a secure fit. Accurate sizing is critical for preventing skin breakdown and leakage.

E. "Use povidone-iodine to clean around the stoma.": Povidone-iodine is harsh and can irritate peristomal skin. Gentle washing with warm water and mild soap is recommended to preserve skin integrity and prevent irritation.

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Correct Answer is A

Explanation

Rationale

A. Acceptance: Acceptance is the stage of grief in which the client comes to terms with their prognosis and makes peace with the situation. Choosing comfort care over further treatment reflects understanding of their terminal condition and a focus on quality of life rather than curative measures. Documentation should reflect the client’s informed decision and readiness to embrace this stage.

B. Denial: Denial involves refusal to acknowledge the reality of the illness or prognosis. The client in this scenario is aware of their condition and is making conscious choices, indicating they are not in denial. Recognizing denial helps identify when clients may need additional support or education.

C. Bargaining: Bargaining involves attempting to negotiate for more time or a different outcome, often through “if only” statements or promises. The client is not seeking alternative treatments or making deals to extend life, so bargaining is not applicable in this case.

D. Depression: Depression is characterized by deep sadness, hopelessness, or withdrawal in response to loss. While the client may experience emotional responses, the statement indicates acceptance rather than pervasive despair. Distinguishing between acceptance and depression ensures accurate documentation of the client’s emotional stage.

A. Contact B. Airborne C. Protective D. Droplet

Correct Answer is B

Explanation

Rationale

A. Contact: Contact precautions are used for infections spread by direct or indirect contact, such as C. difficile or MRSA. Measles is not primarily transmitted via contact, so contact precautions alone are insufficient.

B. Airborne: Measles is highly contagious and transmitted via airborne respiratory droplets that can remain suspended in the air. Airborne precautions, including placing the client in a negative-pressure room and requiring staff to wear N95 respirators, are necessary to prevent transmission.

C. Protective: Protective (or neutropenic) precautions are designed to protect immunocompromised clients from infection. They are not appropriate for preventing the spread of measles from an infected client.

D. Droplet: Droplet precautions are used for infections spread by larger respiratory droplets, such as influenza or pertussis. Measles requires airborne precautions because the virus can travel on smaller particles and remain suspended in the air for extended periods.

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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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