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
A client can withdraw consent at any time. This statement is accurate. Informed consent is a process that involves providing the client with information about a procedure or treatment, including its risks and benefits, to enable them to make an informed decision. A client has the right to withdraw their consent at any point in the process.
Choice B Reason:
A family member should witness the client's consent. The witnessing of informed consent is typically done by a healthcare professional involved in the procedure or a neutral third party, not a family member.
Choice C Reason:
A nurse is responsible for obtaining informed consent. While nurses may assist with the informed consent process by providing information and answering questions, the ultimate responsibility for obtaining informed consent usually lies with the healthcare provider performing the procedure.
Choice D Reason:
A minor who is pregnant is unable to give consent. The ability of a minor to give consent can vary based on jurisdiction and the specific circumstances. In many cases, minors may be able to provide consent for certain medical procedures, particularly if they are deemed mature enough to understand the implications. Being pregnant might not necessarily preclude a minor from giving consent. Legal and ethical considerations regarding minors' consent can vary, and healthcare providers should be aware of local regulations and guidelines.
Correct Answer is A
Explanation
Choice A Reason:
Allowing the family to participate in washing the client's body is appropriate. In Islamic tradition, it's customary for family members or individuals of the same gender to participate in washing the deceased's body. This practice is a part of the Islamic ritual of ghusl (ritual washing). It's respectful and important to honor the religious and cultural customs of the deceased and their family.
Choice B Reason:
Providing the family with an eagle feather for the client's hair is inappropriate. In Islamic traditions, the use of eagle feathers or any specific animal-related items isn't a part of postmortem care rituals. Additionally, incorporating items from other traditions or cultures might not align with the religious practices or beliefs of the deceased and their family.
Choice C Reason:
Encouraging the family to chant a mantra before moving the body is inappropriate. Chanting mantras isn't a practice in Islamic postmortem care. Islamic rituals involve specific prayers and actions according to the teachings of Islam, and chanting mantras isn't a part of this tradition.
Choice D Reason:
Dressing the client in a special amulet provided by the family is inappropriate. The use of amulets or charms isn't typically part of Islamic postmortem rituals. Islamic customs emphasize modesty in dress and following specific rites for the deceased, but incorporating special amulets or charms isn't a common practice.
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