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:
Applying skin sealant on damp skin is not a correct technique when changing an ostomy appliance. Skin should be clean and thoroughly dry before applying any ostomy products. Moisture on the skin can interfere with the adhesion of the pouching system, leading to skin irritation and leakage.
Choice B rationale:
Removing the appliance before emptying the pouch is not the correct technique. Ostomy pouches are designed to be emptied without removing the entire appliance. Removing the pouch unnecessarily can cause discomfort to the client and may damage the surrounding skin. Regular emptying of the pouch while leaving the appliance in place is the appropriate practice.
Choice C rationale:
Ensuring that the skin is slightly damp for better adhesion of the pouch is not accurate. Ostomy pouches adhere best to clean, dry skin. Moisture on the skin can compromise the adhesive seal and lead to skin irritation. Therefore, the skin should be thoroughly dried before applying the ostomy pouching system.
Choice D rationale:
Tracing the size of the stoma onto the skin barrier is the correct technique when changing an ostomy appliance. The opening of the skin barrier (wafer) should match the size and shape of the stoma to ensure a proper fit. Tracing the stoma's size onto the barrier helps in cutting the opening to the appropriate size, preventing leakage and ensuring a secure fit around the stoma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Weight gain is a common side effect of many antipsychotic medications, including haloperidol. While it is important to monitor for this adverse effect, it is not specifically related to the extrapyramidal symptoms associated with haloperidol use.
Choice B rationale:
Dry mouth is a common anticholinergic side effect of antipsychotic medications like haloperidol. Although it is important to monitor for this adverse effect, it is not specifically related to the extrapyramidal symptoms, such as parkinsonism, associated with haloperidol use.
Choice C rationale:
This is the correct answer. Shuffling gait, or parkinsonism, is an extrapyramidal symptom associated with the use of antipsychotic medications like haloperidol. It is a movement disorder characterized by a shuffling walk, rigidity, and tremors. Recognizing and reporting this symptom promptly is crucial, as it may indicate the development of a serious neurological condition called tardive dyskinesia.
Choice D rationale:
Sedation is a common side effect of haloperidol and other antipsychotic medications. While it is important to monitor for sedation, it is not specifically related to the extrapyramidal symptoms associated with haloperidol use, as described in choice C.
Correct Answer is D
Explanation
The correct answer is choice d. Determine any physical signs of injury.
Choice A rationale:
Asking the client for permission to take photographs is important for forensic evidence, but it should not be the first action. The nurse must first ensure the client’s immediate physical well-being.
Choice B rationale:
Providing community sexual assault support contacts is crucial for the client’s long-term support and recovery, but it is not the immediate priority in an emergency assessment.
Choice C rationale:
Documenting the client’s verbatim statements is essential for legal and medical records, but it should follow the initial physical assessment to address any urgent medical needs.
Choice D rationale:
Determining any physical signs of injury is the first priority. This ensures that any immediate medical needs are addressed, which is critical for the client’s safety and well-being.
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