A nurse is reinforcing discharge teaching with a client on 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.
The Correct Answer is B
Choice A reason: Changing the ostomy pouch daily is not necessary and could lead to skin irritation from the frequent removal and application of the adhesive. Ostomy pouches are designed to be worn for several days, and the schedule for changing them can vary based on the type of pouch and individual needs.
Choice B reason: Emptying the ostomy pouch when it is 2/3 full is the correct instruction. This prevents the pouch from becoming too heavy, which could pull on the stoma and cause discomfort or damage. It also reduces the risk of leaks and odors.
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 trimmed to match the size of the stoma to provide a secure fit and prevent leakage of the contents onto the skin, which could cause irritation or infection.
Choice D reason: Applying lotion to the peristomal skin when changing the ostomy pouch is not recommended. Lotions or creams can interfere with the adhesive of the ostomy appliance and reduce the effectiveness of the seal. The peristomal skin should be clean and dry to ensure the best adherence of the ostomy appliance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason : A tongue blade should not be placed in the mouth during a seizure as it can cause injury or obstruct the airway.
Choice B reason: An NG tube, or nasogastric tube, is not typically required in the immediate management of seizures and should not be inserted during an active seizure due to the risk of injury.
Choice C reason: An oral airway may be used to maintain a patent airway during a postictal state if the client is unable to maintain their own airway.
Choice D reason: Wrist restraints are not routinely recommended for clients with seizure disorders as they can cause injury during a seizure. Safe environment and proper positioning are preferred to prevent injury.
Correct Answer is B
Explanation
Choice A reason: The statement that "the spacer should make a whistling sound as you inhale" is not accurate. A whistling sound from the spacer may indicate that the air is being inhaled too quickly and that the user needs to slow down. The purpose of the spacer is to hold the medication released from the inhaler so that it can be inhaled more easily and effectively into the lungs, not to produce a whistling sound.
Choice B reason: Holding one's breath for 10 seconds after inhaling the medication allows for better deposition of the medication in the lungs. This pause gives the medication time to settle in the airways rather than being exhaled too quickly. It is a recommended practice to maximize the effectiveness of the inhaled medication.
Choice C reason: Cleaning the spacer is important to ensure that it works correctly and is free of any residue or debris that could obstruct the medication's path. However, the instruction to "clean the spacer daily with cold water" is incomplete. After rinsing with cold water, the spacer should be left to air dry without rinsing or wiping, as this can create static that affects medication delivery.
Choice D reason: Waiting 30 seconds between puffs is recommended to allow the user to breathe normally for a short period and to prepare for the next dose of medication. This time interval helps to ensure that the second puff is not rushed and that the medication from the first puff has had time to act.
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