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:
Discontinuing supplements containing vitamin C 24 hr before the test is appropriate. This is not necessary for fecal occult blood testing. However, vitamin C supplements should be avoided before certain stool tests that use a chemical reaction involving guaiac.
Choice B Reason:
Placing a thick layer of stool on the specimen card is inappropriate. The client should apply a small amount of stool to the designated area on the specimen card. A thick layer is not required, and excess stool may interfere with the test.
Choice C Reason:
Urinating prior to collecting the stool specimen is appropriate. This instruction is important because it helps prevent contamination of the stool specimen with urine, which could potentially interfere with the accuracy of the test results.
Choice D Reason:
Refraining from consuming pork 7 days before the test is inappropriate. There is no need for the client to avoid consuming pork specifically for fecal occult blood testing. The instructions usually focus on dietary restrictions that could affect the presence of blood in the stool, such as avoiding red meat or certain medications.
Correct Answer is A
Explanation
Choice A Reason:Using direct quotes from the client in the incident report is appropriate because it provides an accurate and objective account of the client's perspective. This is an important part of documenting the incident.
Choice B Reason:Incident reports are meant to be internal documents used for quality improvement and risk management. Noting in the medical record that an incident report was completed is not appropriate, as it could imply liability or affect the legal status of the report.
Choice C Reason:The nurse should not draw conclusions about the cause of the incident in the incident report. The report should contain only objective facts, not assumptions or interpretations.
Choice D Reason:
The nurse should not draw conclusions about the cause of the incident in the incident report. The report should contain only objective facts, not assumptions or interpretations.
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