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 0.5 mL of diluent to the medication is inappropriate action. Ampules typically contain a single-dose of medication in a liquid form, and dilution is not necessary unless specified by the medication order or manufacturer.
Choice B Reason:
This is not necessary as the tip of the ampule is already sterile before opening. Cleansing after opening does not provide additional benefit and can introduce contaminants.
Choice C Reason:
Using a filter needle to aspirate the medication is inappropriate. Filter needles are not routinely used for administering medication from ample.
Choice D Reason:
This is not appropriate for ampules. Unlike vials, ampules do not require air to be injected. Air injection is necessary only for vials to create pressure, but ampules are opened and medication is drawn directly without the need for air.
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.
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