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 A
Explanation
Choice A Reason:
"Call me so that I can help you change your position." This response offers practical assistance and comfort to the client. Repositioning can sometimes alleviate discomfort associated with breathing difficulties, and the nurse can offer guidance or physical help to adjust the client's position for improved comfort.
Choice B Reason:
"Try to close your eyes and get some sleep." This response doesn't directly address the client's immediate concern about difficulty breathing and may not offer practical help.
Choice C Reason:
"It is common for breathing to become more difficult as time goes on." While this statement acknowledges the situation, it might not provide the client with actionable guidance or support on how to manage the difficulty in breathing.
Choice D Reason:
"Therapy choices are limited for clients who do not want resuscitation." This response might be interpreted as dismissive or unrelated to the client's immediate needs, focusing more on the DNR order rather than addressing the current concern about breathing difficulties.
Correct Answer is D
Explanation
Choice Reason:
Occupational Therapist is incorrect. Occupational therapists focus on helping individuals regain or enhance their ability to perform daily activities and tasks. While they might not directly address dysphagia or swallowing concerns, they could assist in modifying the environment or providing adaptive equipment to facilitate eating, such as recommending specialized utensils or adapting seating positions to support safe eating practices.
Choice B Reason:
Physical Therapist is incorrect. Physical therapists primarily concentrate on restoring mobility, strength, and function in individuals who have experienced injuries or illnesses affecting movement. While they might not directly address dysphagia, they could be involved in helping patients with postural adjustments or exercises that indirectly support safe eating and swallowing.
Choice C Reason:
Respiratory Therapist is incorrect. Respiratory therapists specialize in assessing and treating breathing problems and disorders related to the lungs and respiratory system. While they may not focus directly on dysphagia, they can be involved in managing respiratory complications that can arise from aspiration, such as pneumonia. They might assist in suctioning, breathing exercises, or respiratory treatments in cases where aspiration has led to lung issues.
Choice D Reason:
Speech therapists, also known as speech-language pathologists, is correct because it specializes in evaluating and treating communication and swallowing disorders. They work with individuals who have experienced strokes or other conditions affecting swallowing abilities to improve their swallowing function and reduce the risk of aspiration (when food or liquid enters the airway instead of the digestive tract).
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