A nurse is providing discharge teaching to a client who has a new ostomy.
Which of the following instructions should the nurse include?
"Apply sterile gloves when changing your ostomy pouch.”
"Notify the provider if your stoma becomes pink and moist.”
"Empty your ostomy pouch when it is half full.”
"Use a moisturizing soap to cleanse your stoma.”
The Correct Answer is C
Choice A rationale:
Applying sterile gloves when changing the ostomy pouch is essential for infection control. However, this is a standard practice and not specific to the client's condition. While important, it is not the priority instruction for a client with a new ostomy.
Choice B rationale:
Notifying the provider if the stoma becomes pink and moist is crucial information for the client. A pink and moist stoma indicates good blood supply and healing, while changes in color or moisture might indicate complications. This instruction is essential for the client's ongoing care and to prevent potential complications, making choice B the correct answer.
Choice C rationale:
Emptying the ostomy pouch when it is half full is a general guideline to prevent leakage and maintain hygiene.
Choice D rationale:
Soaps with lotions or perfumes may interfere with the pouch seal or cause peristomal skin irritation. Rinse and dry well.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
Client reports lower back pain and pinkish vaginal discharge.
- Explanation: Lower back pain and pinkish discharge can indicate preterm labor, especially given the client’s history of a previous preterm birth.
Uterine contractions every 8 minutes, palpate strong, duration 30 seconds.
- Explanation: Frequent and strong contractions suggest that labor may be progressing, which is concerning at 33 weeks gestation and needs close monitoring.
FHR baseline 145, minimal variability.
- Explanation: Minimal variability in the fetal heart rate (FHR) can be a sign of fetal distress or a lack of fetal well-being, warranting further evaluation.
Cervical exam indicates 2 cm, 50% effaced, 0 station.
- Explanation: Cervical dilation and effacement at 33 weeks gestation indicate that labor is progressing. Given the client's history of preterm birth, this finding is concerning and requires intervention to try to prevent another preterm delivery.
Correct Answer is B
Explanation
A. Incorrect. Absence seizures typically do not have an aura. They are characterized by a sudden and brief loss of awareness without warning.
B. Correct. Absence seizures often involve a brief period of staring and decreased responsiveness. They can indeed be mistaken for daydreaming, as they are not as dramatic as other types of seizures.
C. Incorrect. Absence seizures are usually very brief, lasting only a few seconds (often less than 10 seconds), rather than 30 to 60 seconds.
D. Incorrect. Absence seizures have a sudden and abrupt onset, not a gradual one. They occur without warning and without a preceding aura.
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