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
This step is part of the process when mixing NPH and regular insulin in a single syringe. After injecting air into the NPH insulin vial, you should inject an equal amount of air (in this case, 15 units) into the regular insulin vial to maintain pressure balance. This allows for easy withdrawal of the prescribed doses of each insulin type in the same syringe without causing a vacuum in the vials.
After injecting air into the NPH insulin vial (step 1), the nurse should proceed to inject air into the regular insulin vial (step 2) before withdrawing the insulin doses in the subsequent steps.
Verifying the dosage with another nurse is not necessary in this step, as it is done prior to drawing up the insulin. However, it is good practice to have another nurse double-check the dosage before administration.
Injecting air into the regular insulin vial is not required at this stage. It is only necessary when withdrawing the regular insulin dose.
Placing the cap over the needle should be done after withdrawing the desired dose of insulin and before administering it to the client for safety and to prevent needlestick injuries.
The correct sequence when mixing NPH and regular insulin in a single syringe is as follows:
- Inject air into the NPH insulin vial (in this case, 10 units of air).
- Inject air into the regular insulin vial (in this case, 15 units of air).
- Withdraw the prescribed dose of NPH insulin (10 units) from the NPH vial.
- Withdraw the prescribed dose of regular insulin (15 units) from the regular insulin vial.
So, after injecting air into the NPH insulin vial (step 1), the nurse should proceed to inject air into the regular insulin vial (step 2) before withdrawing the insulin doses in the subsequent steps.
Correct Answer is A
Explanation
Stressors can be categorized as external or internal. External stressors are factors or events in the environment that can cause stress.
In this case, the recent move to a new city is an external stressor because it is an event that has occurred outside of the client and is influencing their current state of stress. Moving to a new city can bring about significant changes and challenges, such as adjusting to a new environment, finding new social connections, and adapting to unfamiliar surroundings.
Feeling depressed is an internal stressor because it relates to the client's emotional state or mental health condition. Depression can be caused by various factors, such as biochemical imbalances, life circumstances, or genetic predispositions.
Lack of nutritional knowledge: This is an internal stressor because it refers to the client's lack of knowledge or awareness regarding nutrition. While the lack of nutritional knowledge can contribute to stress, it is an internal factor that can be addressed through education and learning.
While recurring urinary tract infections can be stressful for the client, they are considered an internal stressor because they involve a physical condition or health issue within the client's body. Addressing and managing the infections would involve medical interventions and possibly lifestyle modifications.
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