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 B

Explanation

A. While staff training is important, it may not address the immediate concern of identifying the cause of the infections.
B. Correct. Identifying the possible factors contributing to the infections is the first step in addressing the issue and preventing further infections.
C. Meeting with providers can be beneficial, but identifying the cause should come first before discussing measures.
D. Revising the policy for catheter care can be considered once the contributing factors are identified.

A. Perform a sterile dressing change for a client who has an abdominal wound. B. Complete discharge teaching for a client who has a new diagnosis of diabetes mellitus. C. Perform an admission assessment for a client who is scheduled for surgery. D. Complete the Glasgow Coma Scale for a client who has an evolving stroke.

Correct Answer is A

Explanation

A. Correct. Performing a sterile dressing change falls within the scope of practice for a licensed practical nurse (LPN).

B. Incorrect. Discharge teaching often involves complex information and considerations, which are typically better suited for a registered nurse.

C. Incorrect. An admission assessment requires comprehensive assessment skills that are typically performed by registered nurses.

D. Incorrect. Completing assessments related to complex neurological changes, such as the Glasgow Coma Scale for a stroke, is typically within the scope of a registered nurse.

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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?

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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?