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 C
Explanation
Choice C rationale:
Avoiding consuming foods containing chocolate is important for individuals with gastroesophageal reflux disease (GERD) Chocolate contains substances that can relax the lower esophageal sphincter, allowing stomach acid to flow back into the esophagus, worsening GERD symptoms. Therefore, the nurse should include this information in the discharge teaching to help the client manage GERD effectively.
Choice A rationale:
Taking antacids that contain mint for heartburn is not recommended. Mint can relax the lower esophageal sphincter, similar to chocolate, potentially worsening GERD symptoms. Therefore, clients with GERD should avoid mint-containing products.
Choice B rationale:
Increasing dietary intake of citrus fruits is not advisable for individuals with GERD. Citrus fruits are acidic and can irritate the esophagus, leading to increased reflux symptoms. Clients with GERD should limit or avoid citrus fruits in their diet.
Choice D rationale:
Lying down for 30 minutes after eating a meal is not a recommended practice for individuals with GERD. Instead, clients with GERD should remain upright for at least 2-3 hours after eating to reduce the risk of reflux. Lying down shortly after a meal can worsen symptoms by allowing stomach acid to flow back into the esophagus more easily.
Correct Answer is A
Explanation
A. Correct. Participating in range-of-motion exercises helps prevent circulation problems and joint stiffness that can result from prolonged immobility after surgery.
B. Incorrect. While elevating the knees can help reduce strain on the lower back, this might not specifically promote circulation.
C. Incorrect. Prolonged bed rest can lead to decreased circulation and increased risk of complications such as deep vein thrombosis (DVT).
D. Incorrect. While using an incentive spirometer is important for preventing respiratory complications, it might not specifically address circulation issues.
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