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."

Answer and Explanation

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.

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Correct Answer is B

Explanation

The nurse should report the possible abuse to adult protective services if an older adult client states that their child took all their money. This is an important nursing intervention to ensure the safety and well-being of the client.

a) Instructing the client to report the theft to the police may be appropriate, but it is not the first action the nurse should take. The nurse has a legal and ethical obligation to report suspected abuse to the appropriate authorities.

c) Asking the client if there is another family member they can call for financial help may be appropriate, but it does not address the issue of possible abuse.

d) Restricting visitation for the client's family until discharge is not appropriate and may violate the client's rights.

A. Flexes the client's aﬀected hip to 120 B. Adducts the client's aﬀected leg C. Checks the neurovascular status of the client's lower extremities every 6 hr D. Applies a sequential compression device to the client's lower extremities

Correct Answer is D

No explanation

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A nurse is reinforcing teaching with a client about caring for a new colostomy. Which of the following statements should the nurse make?

Nursing Test Bank

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