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 A
Explanation
A. Correct. Influenza immunization is recommended for pregnant individuals, and it can be given at any time during pregnancy, especially during flu season.
B. Incorrect. The hepatitis B immunization is safe during pregnancy and can be administered if indicated, regardless of breastfeeding status.
C. Incorrect. Rubella immunization is not recommended during pregnancy due to potential risks to the fetus. It should be given prior to pregnancy or after delivery.
D. Incorrect. Varicella immunization is also not recommended during pregnancy due to potential risks. It should be administered before pregnancy or after delivery if needed.
Correct Answer is ["A","C","D","G"]
Explanation
A. "Try using an abdominal support belt." - An abdominal support belt is recommended to provide support to the growing abdomen and can help alleviate backaches that are common during pregnancy.
B. "Take hot showers to help relieve itching." - This statement is incorrect. Hot showers can actually worsen itching and dry out the skin. Lukewarm showers are recommended instead.
C. "Wear loose-fitting clothing." - This statement is correct. Loose-fitting clothing can provide comfort and reduce irritation, especially in areas experiencing itching.
D. "Wear flat or low-heeled shoes." - This statement is correct. Flat or low-heeled shoes provide better support and stability during pregnancy, reducing the risk of falls.
E. "You can douche twice weekly." - This statement is incorrect. Douching is not recommended during pregnancy as it can disrupt the natural balance of vaginal flora and increase the risk of infections.
F. "Eat two large meals a day." - This statement is incorrect. Eating large meals can lead to discomfort and heartburn. It is better to eat frequent smaller meals throughout the day during pregnancy.
G. "You should avoid fried foods." - This statement is correct. Fried foods can exacerbate heartburn and should be avoided to reduce discomfort.
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