A nurse is providing teaching to a client who has a new colostomy. Which of the following actions should the nurse take when demonstrating how to change the ostomy appliance?
Apply the skin sealant on damp skin.
Remove the appliance before emptying the pouch.
Ensure that the skin is slightly damp for better adhesion of the pouch.
Trace the size of stoma onto the skin barrier.
The Correct Answer is D
Choice A rationale:
Apply the skin sealant on damp skin. Rationale: Applying skin sealant on damp skin is not the recommended approach for securing an ostomy appliance. It's important to ensure that the skin is clean and dry before applying the sealant or the skin barrier. Moisture can compromise adhesion and lead to skin irritation or appliance detachment.
Choice B rationale:
Remove the appliance before emptying the pouch. Rationale: Removing the appliance before emptying the pouch is not a necessary step when changing an ostomy appliance. Typically, the pouch can be emptied without removing the entire appliance, which helps maintain the seal and reduces unnecessary skin exposure.
Choice C rationale:
Ensure that the skin is slightly damp for better adhesion of the pouch. Rationale: Ensuring that the skin is slightly damp is not advisable for better adhesion of the pouch. The skin should be completely dry before applying the pouch to ensure proper adhesion. Moisture on the skin can lead to leakage or detachment of the appliance.
Choice D rationale:
Trace the size of stoma onto the skin barrier. Rationale: This choice is the correct answer because tracing the size of the stoma onto the skin barrier ensures a precise fit, which is crucial for preventing leaks and maintaining the integrity of the ostomy. A proper fit also helps in preventing skin irritation and discomfort. Choosing the correct barrier size based on the stoma's dimensions is a key aspect of effective ostomy care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Providing a cup of hot chocolate prior to bedtime is not a suitable intervention for a client reporting difficulty sleeping. Hot chocolate contains caffeine, which can act as a stimulant and interfere with sleep. Caffeine is known to disrupt sleep patterns and should be avoided close to bedtime.
Choice B rationale:
Scheduling exercise activities at least 3 hours before bedtime is the correct intervention for a client experiencing difficulty sleeping. Regular exercise promotes better sleep quality by helping to regulate the sleep-wake cycle and improve sleep duration. However, exercising too close to bedtime can have a stimulating effect, making it harder for the client to fall asleep. By scheduling exercise activities earlier in the day, the client's body will have sufficient time to wind down before bedtime, leading to improved sleep.
Choice C rationale:
Keeping soft music playing at bedtime and throughout the night might not be effective for everyone. While soft music can create a calming environment and help some individuals relax, it may not address the underlying causes of the client's difficulty sleeping. Additionally, some people might find background noise disruptive to their sleep. Therefore, this option might not be as effective as adjusting the timing of exercise.
Choice D rationale:
Scheduling mealtime 2 hours before bedtime is generally a good practice, but it might not directly address the client's reported difficulty sleeping. Consuming heavy or spicy meals close to bedtime can cause discomfort and indigestion, which might interfere with sleep. However, adjusting mealtime alone might not be sufficient to resolve the client's sleep issues, especially if other factors are contributing to their insomnia.
Correct Answer is A
Explanation
Choice A rationale:
The client's statement about increasing daily intake of calcium and vitamin D indicates an understanding of the teaching related to kyphosis and osteoporosis. Kyphosis is a condition where there is an abnormal curvature of the spine, leading to a hunched-back appearance, and osteoporosis is a condition characterized by weakened bones. Calcium and vitamin D are essential nutrients for maintaining bone health. Calcium is a mineral that is a major component of bones, and vitamin D helps the body absorb calcium from the diet. Adequate intake of these nutrients is crucial for preventing further bone loss and fractures in individuals with kyphosis and osteoporosis.
Choice B rationale:
The client's statement about scheduling an electrophysiologic study is unrelated to the teaching about kyphosis and osteoporosis. Electrophysiologic studies are used to evaluate the electrical activity of the heart, and they are not directly relevant to the client's bone health or the management of kyphosis and osteoporosis.
Choice C rationale:
The client's statement about wearing a neck brace while sleeping to prevent injury is incorrect and indicates a misunderstanding of the teaching. Kyphosis primarily affects the thoracic (upper/mid-back) spine and is not typically associated with wearing a neck brace. Neck braces are more commonly used for cervical spine issues.
Choice D rationale:
The client's statement about avoiding weight-bearing exercise to minimize trauma is incorrect and demonstrates a misunderstanding of the teaching. Weight-bearing exercise, such as walking and strength training, is important for maintaining bone density and muscle strength, which are critical for individuals with kyphosis and osteoporosis. Avoiding weight-bearing exercise could actually lead to further bone loss and weakness.
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