A nurse is reinforcing teaching with a client who has a new ileostomy. Which of the following statements by the client indicates an understanding of the teaching?

will use a skin sealant before I apply the bag."

will use moisturizing soap to clean around the stoma before applying the bag."

will cut the wafer opening one-fourth of an inch larger than the stoma

1 will need to empty the bag every 4 to 6 hours."

Answer and Explanation

The Correct Answer is A

Choice A Reason:

"I will use a skin sealant before I apply the bag." This statement is appropriate. Using a skin sealant before applying the ostomy bag helps protect the skin around the stoma, creating a barrier against irritation and potential leaks from the stool. It demonstrates the client's understanding of preventive measures to maintain skin integrity.

Choice B Reason:

"I will use moisturizing soap to clean around the stoma before applying the bag." This statement is inappropriate. While keeping the area around the stoma clean is important, using moisturizing soap might not be recommended as it can leave residue and interfere with the adhesive properties of the bag. Typically, mild soap and water are recommended for cleansing.

Choice C Reason:

"I will cut the wafer opening one-fourth of an inch larger than the stoma." This statement is incorrect. Cutting the wafer opening one-fourth of an inch larger than the stoma might result in an excessively large opening, potentially leading to leaks or irritation. The ideal size is generally recommended to be as close to the stoma size as possible without causing pressure on the stoma.

Choice D Reason:

"I will need to empty the bag every 4 to 6 hours." This statement is incorrect. While regular emptying of the ostomy bag is necessary, the frequency can vary based on individual needs and stoma output. Some individuals might need to empty it more frequently or less often, depending on their stool output and comfort level.

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Correct Answer is A

Explanation

Choice A Reason:

Passing of flatus is correct. Passing flatus (gas) is an encouraging sign that the digestive system is functioning and that gas is moving through the colostomy. This is a positive indicator of colostomy function.

Choice B Reason:

Stoma is pinkish-red. A pinkish-red stoma indicates good blood circulation to the area, which is vital for the health of the stoma tissue. A healthy-colored stoma is a positive sign.

Choice C Reason:

Tolerating a clear liquid diet. Tolerating a clear liquid diet might be an indicator of gastrointestinal function, but it might not specifically confirm the functionality of the colostomy itself.

D. Absent bowel sounds

Absent bowel sounds might be present immediately postoperatively due to the effects of anesthesia and abdominal surgery. However, bowel sounds aren't a direct indicator of colostomy function.

A. The client's fingers are cool to the touch. B. The client reports severe itching under the cast. C. The client's capillary refill is 3 seconds. D. The client reports increased pain at the area of the fracture.

Correct Answer is A

Explanation

Choice A Reason:

The client's fingers are cool to the touch is correct. Coolness of the fingers within a short time after a cast application can indicate compromised circulation or potential compartment syndrome, which requires urgent attention to prevent tissue damage or loss of function. It suggests impaired blood flow to the fingers, which is a serious concern requiring immediate evaluation by the provider.

Choice B Reason:

The client reports severe itching under the cast is incorrect. While itching can be uncomfortable, it might not pose an immediate threat. Itching can commonly occur as the skin heals and can be managed through non-invasive means.

Choice C Reason:

The client's capillary refill is 3 seconds is incorrect. A capillary refill of 3 seconds is slightly prolonged but doesn't typically indicates an immediate emergency. However, if this finding worsens or if combined with other concerning symptoms, it might warrant further assessment.

Choice D Reason:

The client reports increased pain at the area of the fracture is incorrect. Increased pain after a cast application can be expected initially, especially within 2 hours of the procedure. However, persistent or severe pain could indicate issues like poor alignment, swelling, or other complications. While it's important to address pain, it might not require immediate reporting unless accompanied by other concerning symptoms.

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A nurse is reinforcing teaching with a client who has a new ileostomy. Which of the following statements by the client indicates an understanding of the teaching?

Nursing Test Bank

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