A nurse is reinforcing discharge teaching with a client about how to care for a newly created ileal conduit. Which of the following instructions should the nurse include in the teaching?

Change the ostomy pouch daily.

Empty the ostomy pouch when it is 2/3 full.

Trim the opening of the ostomy seal to be 1/2 inch wider than the stoma.

Apply lotion to the peristomal skin when changing the ostomy pouch.

Answer and Explanation

The Correct Answer is B

Choice A reason: Changing the ostomy pouch daily is not typically necessary. Most pouches can be worn comfortably for several days before needing to be changed. Frequent changes are not only unnecessary but can also irritate the skin around the stoma.

Choice B reason: Emptying the ostomy pouch when it is 2/3 full is recommended to prevent leaks and overfilling, which can lead to discomfort and potential skin irritation. It is important to monitor the fullness of the pouch and empty it regularly to maintain hygiene and comfort.

Choice C reason: Trimming the opening of the ostomy seal to be 1/2 inch wider than the stoma is incorrect. The opening should be cut to match the size of the stoma to ensure a snug fit that prevents leakage and protects the skin around the stoma.

Choice D reason: Applying lotion to the peristomal skin when changing the ostomy pouch is not advised. Lotions or creams can interfere with the adhesive of the ostomy appliance and should be avoided. The peristomal skin should be clean and dry to ensure proper adhesion of the ostomy appliance.

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Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason: Moving the cane 2 feet ahead is too far and can cause imbalance or a fall. The cane should be moved a short distance ahead, about the length of one natural step.

Choice B reason: Holding the cane with the right hand is correct for someone with left-sided weakness. The cane should be used on the stronger side of the body to provide support for the weaker side.

Choice C reason : Taking a step with the left foot first is not correct because the weaker leg should be advanced to the cane to ensure stability and support when moving.

Choice D reason: Advancing the weaker leg forward to the cane is correct. The cane provides support for the weaker leg, helping to maintain balance as the client walks.

A. Move the client to a double room. B. Use a bed alarm. C. Encourage participation in activities that provide excessive stimulation. D. Use chemical restraints at bedtime.

Correct Answer is B

Explanation

Choice A reason: Moving the client to a double room may not be effective in preventing wandering and could potentially lead to confusion or agitation if the client is not comfortable with the roommate or the new environment.

Choice B reason: Using a bed alarm is a non-invasive way to alert staff if the client attempts to leave the bed. This can help prevent wandering and ensure the safety of the client without restricting their movement unnecessarily.

Choice C reason: Encouraging participation in activities that provide excessive stimulation is not recommended for clients with dementia, as it can lead to increased confusion, agitation, and potentially exacerbate wandering behaviors.

Choice D reason: The use of chemical restraints, such as sedative medications, should be a last resort and only used when necessary to ensure the safety of the client or others. It is important to use the least restrictive measures first and to always consider the ethical implications of using chemical restraints.

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A nurse is reinforcing discharge teaching with a client about how to care for a newly created ileal conduit. Which of the following instructions should the nurse include in the teaching?

Nursing Test Bank

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