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.”

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Administering the medication 30 minutes earlier may not be appropriate without specific orders from the provider.
B. Infusing the medication at a faster rate is not a solution for adjusting the timing of the dose.
C. Administering the medication up to 2 hours after the usual schedule time is incorrect because it could lead to subtherapeutic levels and reduced effectiveness.

D. Adjusting the medication schedule solely for the convenience of the client without consulting the provider is not recommended.

A. "I can continue to take St. John's wort while taking this medication." B. "I should take this medication on an empty stomach." C. "I expect this medication to raise my blood pressure." D. "I know it will be a couple of weeks before the medication helps me feel better."

Correct Answer is D

Explanation

A. St. John's wort is an herbal supplement that can interact with antidepressant medications like amitriptyline and should be avoided.
B. Taking amitriptyline on an empty stomach can lead to gastrointestinal upset, so it is better to take it with food.
C. Amitriptyline can have anticholinergic effects, which might lower blood pressure rather than raise it.
D. Correct. Amitriptyline and other antidepressants take a few weeks to reach their full therapeutic effect, so it's important for the client to understand this delayed response.

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A nurse is providing discharge teaching to a client who has a new ostomy. Which of the following instructions should the nurse include?

Nursing Test Bank

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A nurse is providing discharge teaching to a client who has a new ostomy.
Which of the following instructions should the nurse include?