A nurse is reinforcing teaching with another nurse about how to change an ostomy appliance for a client who has a sigmoid colostomy.
Which of the following instructions should the nurse include in the teaching?
Create an opening on the skin barrier that is 1.27 cm (0.5 in) larger than the client's stoma
Use a moisturizing soap to clean the skin around the client's stoma
Empty the client's ostomy pouch before removing the skin barrier
Change the client's ostomy appliance 1 hr after breakfast
Correct Answer : C
A. Create an opening on the skin barrier that is 1.27 cm (0.5 in) larger than the client's stoma. The opening on the skin barrier should be cut to fit closely around the stoma, approximately 0.3-0.6 cm (1/8 to 1/4 inch) larger than the stoma size. A larger opening (like 0.5 inches) could expose too much surrounding skin, increasing the risk of skin irritation from contact with the stoma's effluent.
B. Use a moisturizing soap to clean the skin around the client's stoma. Moisturizing soaps should be avoided because they can leave a residue on the skin, which may interfere with the adhesion of the ostomy appliance. The skin around the stoma should be cleaned with mild soap and water, or water alone, and then dried thoroughly before applying the new appliance.
C. Empty the client's ostomy pouch before removing the skin barrier. Emptying the ostomy pouch before removing the skin barrier is a practical step to reduce spillage of stool during the appliance change, making the process cleaner and easier to manage. It also minimizes the risk of contamination of the surrounding area or wound.
D. Change the client's ostomy appliance 1 hour after breakfast. Ostomy appliances are best changed when the bowel is least active, which is usually before a meal or several hours after eating. Changing the appliance shortly after a meal, such as 1 hour after breakfast, may result in more stoma output, making it harder to manage the appliance change.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Explanation B.Triiodothyronine
Levothyroxine is a synthetic form of the thyroid hormone thyroxine (T4). It is converted to triiodothyronine (T3), the active form of the thyroid hormone, in the body. Monitoring the levels of triiodothyronine (T3) can help assess the effectiveness of levothyroxine therapy and ensure that the client's thyroid hormone levels are within the desired therapeutic range.
Serum potassium levels in (option A) should not be monitored because they are not directly affected by levothyroxine. However, imbalances in electrolytes can occur in some individuals with thyroid disorders. Electrolyte levels may be monitored, but it is not the primary focus of monitoring for levothyroxine therapy.
Blood urea nitrogen (BUN) in (option C) should not be monitored because it is a test used to assess kidney function and is not directly related to monitoring levothyroxine therapy.
Prothrombin time (PT) in (option D) should not be monitored because it is a test used to evaluate the clotting function of the blood and is not specifically related to monitoring levothyroxine therapy.
Correct Answer is ["B"]
Explanation
a. Asking other group members to limit their speaking may place unnecessary pressure on the quiet client and make them feel singled out. The goal is to create a supportive environment where the client feels comfortable contributing when they are ready. Limiting the other group members' participation does not address the individual needs of the client who is silent.
b.Some clients may need extra time to process information or formulate their responses, particularly in a group setting where they might feel overwhelmed or anxious. Allowing the client extra time respects their pace and encourages participation without pressuring them.
c.Appointing the client to lead the discussion if they cannot contribute are not appropriate actions. These approaches can increase the client's discomfort and create a negative atmosphere, which goes against the principles of group therapy. It is important to foster an inclusive and supportive environment that encourages participation at each person's pace.
d.Telling a client to leave the group if they cannot contribute is not appropriate action. These approaches can increase the client's discomfort and create a negative atmosphere, which goes against the principles of group therapy.
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