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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Explanation
D, Elevated ammonia
Cirrhosis is a chronic liver disease characterized by the progressive scarring of liver tissue. As liver function becomes impaired, there is a decrease in the liver's ability to metabolize and detoxify substances, including ammonia. Elevated ammonia levels in the blood, known as hyperammonemia, are commonly seen in clients with advanced cirrhosis.
Elevated amylase in (option A) is incorrect because it is typically seen in conditions affecting the pancreas, such as pancreatitis, and is not specific to cirrhosis.
Decreased bilirubin levels in (option B) is incorrect because they are not expected in cirrhosis. In fact, bilirubin levels are often elevated in cirrhosis due to impaired liver function and the accumulation of bilirubin in the blood.
Elevated lipase in (option C) is incorrect because it is typically seen in pancreatic disorders, such as pancreatitis, and is not specific to cirrhosis.
Correct Answer is B
Explanation
During an intravenous pyelogram (IVP), a contrast dye is injected into the client's veins, and X-ray images are taken to visualize the urinary tract. The dye used in an IVP can cause a warming or flushing sensation as it circulates through the body. The client's statement indicates an understanding of this common sensation associated with the procedure.
"I can have a meal up to 2 hours before the procedure": This statement is incorrect. Typically, for an IVP, the client is required to have an empty stomach before the procedure to ensure accurate imaging results. The client should follow the specific instructions provided by their healthcare provider regarding fasting before the procedure.
"I do not need to sign a consent form before this procedure": This statement is incorrect. Informed consent is required for most medical procedures, including an IVP. The client should sign a consent form after receiving all the necessary information about the procedure, its risks, and benefits.
"I should limit my fluid intake for 2 days after the procedure": This statement is incorrect. After an IVP, it is generally advised to increase fluid intake to help flush out the contrast dye from the body and prevent potential complications. The client should follow the specific instructions provided by their healthcare provider regarding post-procedure fluid intake.
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