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 C
Explanation
The nurse should apply a heat pack 5 to 10 minutes prior to the procedure when planning to obtain blood from a newborn via a heel stick. This helps to increase blood flow to the area and makes it easier to obtain the specimen.
a) Puncturing the heel to a depth of 4 mm is too deep and can cause injury to the newborn. The recommended depth for a heel stick is 2.4 mm or less.
b) Withholding feeding prior to collecting the specimen is not necessary.
d) Elevating the newborn's foot for 15 minutes following the procedure is not necessary.
Correct Answer is D
Explanation
When a mother states that she should have her baby latch on to both the nipple and areola during breastfeeding, it demonstrates an understanding of the correct latch technique. A proper latch involves the baby taking in not just the nipple but also a portion of the surrounding areola. This ensures effective milk transfer and helps prevent nipple soreness or damage.
"My baby should breastfeed 5 to 10 minutes on each breast": This statement is not entirely accurate. It is important to understand that breastfeeding duration can vary among infants, and there is no fixed timeframe for how long a baby should breastfeed on each breast. Some infants
may nurse for shorter periods, while others may take longer. The focus should be on ensuring that the baby is effectively nursing and getting enough milk rather than adhering strictly to a specific time limit.
"I should keep my baby on a strict feeding schedule": This statement is incorrect. Breastfeeding on demand, also known as responsive feeding, is generally recommended for newborns.
Newborns should be fed whenever they show signs of hunger, such as rooting, sucking motions, or increased alertness. Strict feeding schedules can interfere with the baby's natural feeding cues and hinder milk supply establishment.
"I should not wake my baby during the night to breastfeed": This statement is not accurate, especially for a 5-day-old newborn. Newborns typically need frequent feeding, including during the night, to meet their nutritional needs and support proper growth and development. It is generally recommended to wake a sleeping newborn every 2-3 hours during the night to ensure adequate feeding and prevent excessive weight loss.
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