A nurse is reinforcing teaching with another nurse about how change an ostomy appliance for a client who has sigmoid colostomy. Which of the following instructions should the nurse include in the teaching?
Use a moisturizing soap to clean the skin around the client's stoma.
Create an opening on the skin barrier that is 1.27 cm (0.5 in) larger than the client's stoma.
Empty the client's ostomy pouch before removing the skin barrier.
Change the client's ostomy appliance hr after breakfast.
The Correct Answer is C
A) Use a moisturizing soap to clean the skin around the client's stoma:
Using a moisturizing soap is not recommended for cleaning the skin around the stoma. Moisturizing soaps can leave a residue that may interfere with the adhesion of the ostomy appliance. The skin around the stoma should be cleaned with warm water and mild soap that does not contain lotions, fragrances, or oils. This helps ensure the skin is clean and dry, promoting better adhesion of the skin barrier.
B) Create an opening on the skin barrier that is 1.27 cm (0.5 in) larger than the client's stoma:
The opening in the skin barrier should be about 1/8 inch (approximately 0.32 cm) larger than the stoma's diameter, not 1.27 cm (0.5 in) larger. A larger opening can cause the skin barrier to fit too loosely, leading to leakage and skin irritation. The skin barrier should fit snugly around the stoma to prevent any leakage and protect the surrounding skin.
C) Empty the client's ostomy pouch before removing the skin barrier:
It is essential to empty the ostomy pouch before removing the skin barrier to prevent fecal material from spilling or leaking during the appliance change. This helps maintain cleanliness, reduces the risk of skin irritation, and makes the procedure more comfortable for both the client and the nurse.
D) Change the client's ostomy appliance 1 hour after breakfast:
There is no specific time required after breakfast to change the ostomy appliance. The timing of appliance changes should be based on the client's individual needs and lifestyle, and it is more important to change the appliance when necessary (e.g., when the pouch is full or when the skin barrier is no longer intact) rather than adhering to a specific time after meals.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) "I will stop what I am doing and lie down.": This is the correct response. When a client with stable angina experiences chest pain, they should stop any physical activity and rest in a comfortable position, preferably lying down. This helps reduce the heart’s workload and decrease the demand for oxygen, which can relieve the pain. Rest is important before taking any further action.
B) "I will take two 325 milligram aspirin tablets at the same time.": While aspirin can help reduce blood clot formation in some cases of chest pain, the recommended dosage is typically one 81-325 mg aspirin, not two 325 mg tablets. Taking two large doses may lead to an overdose or unwanted side effects. Additionally, this is not the immediate intervention for stable angina pain, which typically responds to rest and nitroglycerin.
C) "I will hold my breath and bear down.": This technique, known as the Valsalva maneuver, can increase intrathoracic pressure and slow the heart rate, but it is not recommended to relieve chest pain in stable angina. In fact, it could increase stress on the heart and worsen the symptoms. This maneuver is used in specific situations, such as slowing a rapid heart rate, not for chest pain relief.
D) "I will call the provider after taking one dose of nitroglycerin.": The client should first try nitroglycerin for chest pain as prescribed, and if the pain doesn’t resolve after one dose (or if it worsens), they should seek medical attention. However, in the case of stable angina, it's more appropriate to call the provider if the chest pain persists despite rest and nitroglycerin, not immediately after the first dose.
Correct Answer is A
Explanation
A) A recent move to a new city: A move to a new city is an example of an external stressor. External stressors are environmental or situational factors that create stress, such as life changes, events, or challenges in the outside world. Relocating can involve significant adjustments, such as adapting to a new community, finding housing, and establishing new social connections, all of which can cause stress.
B) Lack of nutritional knowledge: Lack of nutritional knowledge is an internal stressor, as it involves an individual's beliefs, attitudes, and understanding. While it can cause stress, it is a personal factor rather than an external, environmental one.
C) Report of feeling depressed: Feelings of depression are an internal stressor because they are related to an individual’s emotional state or mental health. This reflects the client's internal experience rather than an external environmental factor.
D) Recurring urinary tract infections: Recurring urinary tract infections (UTIs) are a health-related concern and can be seen as a physiological stressor. However, they are not strictly external; they are related to the individual’s health and body rather than external environmental circumstances.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.