A nurse is reinforcing teaching about ostomy supplies with a client who has a new colostomy. Which of the following information should the nurse include?

Empty the pouch when it is 1/3 to 1/2 full.

Use a standard enema set to irrigate the colostomy.

Cleanse the skin surrounding the stoma with moisturizing soap.

Cut the opening in the skin barrier 1/4 inch larger than the stoma.

Answer and Explanation

The Correct Answer is A

A. Empty the pouch when it is 1/3 to 1/2 full: This prevents the weight of the pouch from causing leaks or pulling on the stoma.
B. Use a standard enema set to irrigate the colostomy: This is incorrect as a standard enema set is not typically used. Colostomy irrigation requires specific equipment and is not performed routinely.
C. Cleanse the skin surrounding the stoma with moisturizing soap: Moisturizing soap can leave a residue that interferes with adhesive barriers. Mild, non-moisturizing soap or just water should be used.
D. Cut the opening in the skin barrier 1/4 inch larger than the stoma: The opening should fit closely to the stoma to protect the surrounding skin from irritation and leakage.

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Correct Answer is ["A","B","E"]

Explanation

A. Current medication prescriptions: Ensures continuity of care and proper medication administration in the ICU.
B. Primary health problem: Provides the ICU team with context about the client’s current condition and reason for transfer.
C. Number of family members who have visited: This is not clinically relevant to the client's care.
D. Admission vital signs from 1 week ago: Historical vitals are not as critical as current or recent findings.
E. Scheduled times for dressing changes: Provides critical information about ongoing wound care needs.

A. Changed mental status B. Temperature 37.3° C (99.1° F) C. WBC count 9,000/mm3 (5000 to 10,000/mm3) D. Diminished reflexes

Correct Answer is A

Explanation

A. Changed mental status: Older adults often exhibit atypical signs of infection, such as confusion, agitation, or other changes in mental status, rather than classic symptoms like fever or dysuria.
B. Temperature 37.3° C (99.1° F): This temperature is within normal range and does not indicate an infection. Older adults may not always mount a fever with infections.
C. WBC count 9,000/mm³ (5,000 to 10,000/mm³): This is within the normal range, so it does not suggest infection. An elevated WBC count (>10,000/mm³) may indicate an infection.
D. Diminished reflexes: This is not a symptom of a bladder infection. It is more commonly associated with neurological or musculoskeletal conditions.

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A nurse is reinforcing teaching about ostomy supplies with a client who has a new colostomy. Which of the following information should the nurse include?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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