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 gait involves both crutches advancing simultaneously followed by both legs.

B. This gait involves swinging both legs and crutches forward at the same time.

C. This gait involves alternating movement of each crutch and leg, providing more stability but may be difficult for a client with limited weight-bearing on one leg.
D. In this gait, the client advances both crutches and the affected leg simultaneously, followed by the unaffected leg.

A. Bounding pulses B. Restlessness C. Warm skin D. Brisk capillary refill

Correct Answer is B

Explanation

A. Active bleeding with significant blood is characterized by weak and thread pulses and not bounding pulses.
B. Restlessness can be a sign of hypovolemia and decreased tissue perfusion, which may occur with active bleeding.
C. Warm skin may not necessarily indicate active bleeding but rather normal thermoregulation or vasodilation.
D. Brisk capillary refill is a sign of adequate peripheral perfusion and is not typically associated with active bleeding which is characterized by delayed capillary refill.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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