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 B
Explanation
A. Incorrect. The natural loss of deciduous (baby) teeth typically begins around 6 years of age, not at 2 years old.
B. Correct. Toddlers often have a nontender, protruding abdomen due to their underdeveloped abdominal muscles.
C. Incorrect. The fontanels (soft spots on the baby's head) should be closed by 18-24 months of age. Palpable fontanels at 2 years old could indicate abnormal cranial development.
D. Incorrect. It is not typical for a 2-year-old's head circumference to exceed their chest circumference. Head circumference is usually greater in infants but gradually becomes similar to chest circumference by 1-2 years of age.
Correct Answer is C
Explanation
Choice A rationale:
Covering appliance cords with throw rugs is not an appropriate action to address the needs of a client with vision loss and medication management. While it promotes safety by reducing tripping hazards, it does not directly address the client's medication administration needs. Implementing measures that specifically assist the client in managing medications safely is essential in this scenario.
Choice B rationale:
Visiting the client once per month to assess medication usage is insufficient for an older adult with vision loss who takes medications throughout the day. Regular and more frequent assessments are necessary to ensure the client's safety and adherence to the medication regimen. The nurse should consider more proactive measures to support the client, such as providing medication organizers or arranging for a home healthcare aide to assist with medication administration daily.
Choice C rationale:
This is the correct answer. Using container lids of different shapes to indicate times of administration is an effective strategy for clients with vision loss. Associating specific shapes with different times of the day helps the client differentiate between medications, promoting accurate dosing. This method is tactile and easy for the client to understand, enhancing their ability to manage medications independently and safely.
Choice D rationale:
Rearranging furniture to clear walkways is a general safety measure but does not specifically address the client's medication administration needs. While it can prevent falls and accidents, it does not facilitate the client's ability to distinguish between different medications or their dosing schedules. The focus should be on implementing strategies that directly support the client in managing their medications effectively despite their visual impairment.
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