A nurse is reinforcing teaching with a client about caring for a new colostomy. Which of the following statements should the nurse make?
"You should scrub the skin around the colostomy when cleaning."
"You can use an adhesive remover when changing the colostomy skin barrier."
"You will need a device to suction stool from the colostomy bag."
"You should empty the colostomy bag when it is three-fourths full."
The Correct Answer is B
b. "You can use an adhesive remover when changing the colostomy skin barrier."
The nurse should inform the client that they can use an adhesive remover when changing the colostomy skin barrier. Adhesive removers are helpful in gently removing the adhesive residue left behind by the previous ostomy appliance. This can make the process of changing the colostomy skin barrier more comfortable for the client and help prevent skin irritation or damage.
Explanation for the other options:
a. "You should scrub the skin around the colostomy when cleaning." Scrubbing the skin around the colostomy can be harsh and may cause skin irritation or damage. It is recommended to clean the peristomal skin gently using mild soap and water, followed by thorough drying.
c. "You will need a device to suction stool from the colostomy bag." Suctioning stool from the colostomy bag is not a routine procedure for colostomy care. Colostomy bags are designed to collect stool, and emptying the bag as needed is the appropriate method of management.
d. "You should empty the colostomy bag when it is three-fourths full." The timing of emptying the colostomy bag may vary for each individual. It is generally recommended to empty the colostomy bag when it is one-third to one-half full to prevent leakage or discomfort. The client should be educated on monitoring the bag and emptying it as necessary based on their own output and comfort level.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A:
An absent dorsal pedal pulse would indicate a vascular problem such as arterial occlusion, not a deep vein thrombosis (DVT). In the case of DVT, blood flow in the veins is obstructed, but the arterial pulse, which is related to arterial circulation, should remain intact unless there is a separate arterial issue. Therefore, absent pulses are not characteristic of DVT.
Choice B:
Shiny, hairless skin is a sign typically associated with chronic arterial insufficiency, not DVT. This skin change occurs when there is poor arterial blood flow, which leads to a lack of nourishment for the skin, causing it to become thin and shiny. In contrast, DVT affects the veins and does not usually cause these skin changes in the acute phase.
Choice C:
Irregular, bulging veins are indicative of varicose veins or chronic venous insufficiency, not a DVT. Varicose veins occur when the veins become swollen and twisted due to weak or damaged valves. DVT, on the other hand, involves the formation of a clot in the deep veins and does not typically cause the veins to bulge visibly, especially in the early stages.
Choice D:
Dull, aching pain is a common symptom associated with deep vein thrombosis. This pain typically occurs in the affected extremity and is often described as a constant, aching sensation. The pain can worsen with movement or standing and is due to the inflammation and obstruction caused by the blood clot in the deep veins. This is a hallmark sign of DVT, along with swelling and redness in the affected limb.
Correct Answer is B
Explanation
b. "I should join a support group to help me be successful."
The statement that indicates an understanding of smoking cessation teaching is option b: "I should join a support group to help me be successful." Joining a support group is a beneficial strategy for quitting smoking as it provides social support, encouragement, and shared experiences with others who are also trying to quit.
Option a is incorrect because using nicotine patches does not allow for continued smoking as it delivers nicotine without the harmful effects of smoking.
Option c is incorrect because nicotine replacement therapy (NRT) is a safe and effective method to manage nicotine withdrawal and does not cause cancer.
Option d is incorrect because varenicline is a medication that helps reduce nicotine cravings and withdrawal symptoms, and it does not make a person addicted to nicotine.
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