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 C

Explanation

Given the client's symptoms of constant chest pressure that is unrelieved with rest, along with the client's appearance of anxiety, pallor, and diaphoresis, it indicates a high likelihood of an acute coronary event, such as a myocardial infarction (heart attack). In this situation, the nurse should prioritize immediate actions that address the potential cardiac emergency.

Aspirin is an essential medication in the initial management of acute coronary syndrome, including unstable angina and myocardial infarction. It helps to inhibit platelet aggregation and reduce the risk of clot formation in the coronary arteries. The chewable form of aspirin is recommended because it allows for more rapid absorption.

While evaluating extremities for perfusion, pulse volume, and pitting edema is important in assessing the client's overall cardiovascular status, it is not the immediate next step when faced with a suspected acute coronary event.

Securing client consent for coronary angiography and percutaneous coronary intervention (PCI) is a relevant step in the management of unstable angina and myocardial infarction, but it is not the immediate action to be taken in the emergency department. The client requires stabilization and initial medical interventions before procedural consent can be obtained.

Placing an indwelling urinary catheter and instituting strict intake and output measurements is not a priority action in this situation. The focus should be on addressing the potential acute coronary event and ensuring the client's cardiac stability. Urinary catheterization and monitoring of intake and output can be considered later, if necessary.

A. Canned black beans B. Cheese C. Fish D. Red meat

Correct Answer is C

Explanation

A. Canned black beans are a good source of fiber and protein, but they are not specifically recommended for hypertension.
B. Cheese is often high in saturated fat and sodium, which can contribute to hypertension and cardiovascular risk.
C. Correct. Fish, especially fatty fish like salmon, mackerel, and trout, are rich in omega-3 fatty acids, which have been associated with cardiovascular benefits, including reducing blood pressure.
D. Red meat is often high in saturated fat and is not typically recommended for individuals with hypertension.

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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

Naxlex Comprehensive Predictor Exams

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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?