A nurse is reinforcing teaching with a client who has an ostomy. Which of the following statements by the client indicates an understanding of the teaching?
"I will press on the skin barrier for 30 seconds to ensure that it adheres."
"I will clean around the stoma with a moisturizing soap."
"I will apply a thin layer of talc powder around the stoma before placing the appliance."
"I will cut an opening in the skin barrier that is 1⁄2 inch larger than the stoma."
The Correct Answer is A
Choice A Reason:
Pressing on the skin barrier for about 30 seconds ensures that it adheres properly to the skin, which helps secure the ostomy appliance and prevents leakage.
Choice B Reason:
Moisturizing soap is not recommended for cleaning around the stoma, as it can leave a residue that interferes with the appliance's adhesion. Mild soap without moisturizers or just water should be used.
Choice C Reason:
Applying talc powder around the stoma can prevent the appliance from adhering properly, leading to leakage. It is not recommended for ostomy care.
Choice D Reason:
The skin barrier should be cut to fit closely around the stoma, leaving no more than a 1/8 inch gap, not 1/2 inch. A larger opening may cause skin irritation or leakage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Adding diluent to the medication is not appropriate for ampules. Ampules typically contain a single-dose of medication in a liquid form.
Choice B Reason:
The ampule should be cleansed before opening to remove any potential contaminants. Once the ampule is opened, the inside of the ampule and the medication should be considered sterile, so there is no need to cleanse the tip after opening.
Choice C Reason:
A filter needle is used to prevent any glass particles from entering the syringe when drawing medication from an ampule, as ampules are made of glass that can sometimes break and leave shards.
Choice D Reason:
Injecting air into the ampule is not necessary. Ampules are designed to allow for the withdrawal of medication without the need to inject air.
Correct Answer is B
Explanation
Choice A Reason:
To an insurance agency in regard to a life insurance policy . This situation is incorrect. Generally, disclosure of health information to an insurance agency requires the client's written consent.
Choice B Reason:
To a medical interpreter service on behalf of a client. This situation is correct. In healthcare settings, it is generally acceptable to share limited health information with a medical interpreter service to facilitate communication with the client, especially if the client has limited proficiency in the primary language spoken in the healthcare setting. The interpreter is bound by confidentiality rules similar to healthcare providers.
Choice C Reason:
To a family member when the client is not available. This situation is incorrect. Disclosing health information to a family member typically requires the client's consent unless there are specific circumstances, such as emergencies, where the healthcare provider may need to act in the best interest of the client.
Choice D Reason:
To an employer for a pre-employment screening. This situation is incorrect. Disclosing health information to an employer typically requires the client's written consent. Employment-related health information is usually protected by privacy laws.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today