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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is ["30"]

Explanation

To calculate the drip rate, follow these steps:

The client needs to receive 120 mL of lactated Ringer's over 1 hour (60 minutes).
The IV tubing has a drip factor of 15 drops per mL (15 gtt/mL).
Multiply the total volume (120 mL) by the drip factor (15 gtt/mL), which gives 1,800 drops.
Divide this by the total time in minutes (60 minutes).

1,800 drops ÷ 60 minutes = 30 drops per minute (30 gtt/min)

Final Answer:

30 gtt/min

A. Facial erythema B. Peeling of the hands and feet C. Fever D. Beefy, red tongue

Correct Answer is C

Explanation

A. Facial erythema is not a primary diagnostic feature of this specific respiratory bacterial infection. While intense coughing fits may cause temporary facial flushing or venous congestion, it is not a hallmark finding. Conditions like fifth disease or slapped-cheek syndrome are more likely to present with persistent malar rashes. This sign lacks the specificity required for a pertussis diagnosis.

B. Peeling of the skin on the extremities, known as desquamation, is classically associated with Kawasaki disease or scarlet fever. Bordetella pertussis does not typically produce the exotoxin profile necessary to cause significant integumentary shedding or widespread dermatological involvement. The pathology of pertussis is primarily localized to the ciliated epithelium of the respiratory tract. It is not an exfoliative disease.

C. In the catarrhal phase of the infection, a low-grade temperature is a standard clinical finding as the immune system responds to the initial bacterial colonization. The presence of systemic inflammation results in mild pyrexia alongside coryza. This manifestation is most prominent before the onset of the characteristic paroxysmal cough. Fever helps differentiate early pertussis from non-inflammatory conditions.

D. A beefy, red tongue, often described as a strawberry tongue, is a classic sign of scarlet fever or toxic shock syndrome. This manifestation occurs due to capillary permeability and inflammation of the lingual papillae caused by Streptococcus pyogenes. Pertussis involves the respiratory mucosa rather than the oral structures or the tongue. This symptom indicates a different bacterial or inflammatory etiology.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["30"]

Explanation

Final Answer:

A nurse is collecting data from a child who has pertussis. Which of the following manifestations should the nurse expect?

Correct Answer is C

Explanation

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