A nurse is reinforcing teaching about colostomy care with a client. Which of the following client statements indicates an understanding of how to care for the colostomy?
"I will cleanse the stoma site gently with an antiseptic solution."
"I will contact my doctor right away if my stoma is red."
"I will cut the wafer opening 1 inch bigger than my stoma."
"I will empty the colostomy bag when it is one-half full.”
The Correct Answer is D
A. "I will cleanse the stoma site gently with an antiseptic solution.": The stoma and surrounding skin should be cleaned with warm water and mild, non-irritating soap if needed. Antiseptic solutions can irritate the skin and damage the stoma, so this is not recommended.
B. "I will contact my doctor right away if my stoma is red.": Mild redness around the stoma can be normal due to friction or recent appliance changes. Immediate contact is warranted only if there are additional signs of infection, severe irritation, or unusual bleeding. Routine redness alone is not necessarily a cause for urgent concern.
C. "I will cut the wafer opening 1 inch bigger than my stoma.": The appliance opening should closely fit the stoma, typically allowing a 1/8 to 1/4 inch clearance. Cutting the wafer 1 inch larger would leave skin exposed to effluent, increasing the risk of irritation, breakdown, and leakage.
D. "I will empty the colostomy bag when it is one-half full.": Emptying the colostomy bag when it is about one-half to two-thirds full helps prevent leakage and reduces the weight on the appliance, which supports skin integrity and ensures proper functioning. This statement reflects correct understanding of colostomy care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The client cannot withhold consent once it is given: Clients retain the right to withdraw consent for treatment at any time, even in a mental health facility. Involuntary commitment does not eliminate autonomy over medical decisions, and healthcare providers must respect ongoing consent or refusal for treatments when the client is capable of making decisions.
B. The client is not permitted to refuse medications: Clients have the right to refuse medications unless a court order or emergency situation justifies involuntary administration. Informed refusal is a protected legal right, and coercion without due process violates patient autonomy and legal protections.
C. The client should be in the most restrictive environment: Legal and ethical standards require that clients be treated in the least restrictive environment that meets their safety and treatment needs. Placement in the most restrictive setting is not mandated and may only occur if necessary for protection or treatment efficacy.
D. The client is permitted to have visits by clergy: Clients retain the right to access spiritual care and communicate with clergy, regardless of involuntary commitment status. This right is protected under mental health law and supports the client’s freedom of religion and access to personal support systems.
Correct Answer is B
Explanation
A. Assist the client with positioning for an ultrasound: Positioning for ultrasound is part of the preparation for amniocentesis, not a post-procedure intervention. After the procedure, the priority is monitoring the client for complications rather than repeating imaging unless clinically indicated.
B. Monitor the client for placental abruption: Amniocentesis carries a small risk of complications such as bleeding, cramping, or placental injury. Monitoring the client for signs of placental abruption, including vaginal bleeding, abdominal pain, and uterine tenderness, is an appropriate post-procedure action to ensure early detection and intervention.
C. Administer Rh.D immune globulin to the client: Administration of Rh.D immune globulin is indicated for Rh-negative clients to prevent isoimmunization. Since this client is Rh-positive, they do not require Rh immunoglobulin, so this action is not necessary.
D. Obtain an umbilical blood sample from the fetus: Umbilical blood sampling (cordocentesis) is a separate diagnostic procedure and is not part of routine amniocentesis. Post-procedure care focuses on maternal monitoring and fetal well-being rather than obtaining fetal blood immediately.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.