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

Answer and Explanation

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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Correct Answer is C

Explanation

A.Wearing a face mask does not increase the risk of injury. In fact, it helps protect the client from infections, especially if they have concurrent neutropenia, which is common in conditions affecting the bone marrow.

B.Green, leafy vegetables are rich in vitamin K, which plays a role in clotting. However, they do not directly increase the risk of injury in a client with thrombocytopenia. While vitamin K affects clotting factors, thrombocytopenia primarily involves a deficiency of platelets, which are necessary for clot formation.

C.Clients with thrombocytopenia have a low platelet count, which increases their risk of bleeding. Using a firm-bristled toothbrush can cause gum trauma and bleeding, leading to complications such as prolonged bleeding or infection. A soft-bristled toothbrush or an alternative oral hygiene method (such as an oral swab) is recommended to minimize injury.

D.Adequate sleep does not increase the risk of injury. In fact, it may support overall health and immune function.

A. Cantaloupe B. Sweet potato C. Orange juice D. Baked chicken breast

Correct Answer is D

Explanation

Potassium is an essential electrolyte that plays a crucial role in various bodily functions. However, for individuals with an electrolyte imbalance, it is often necessary to limit their potassium intake. Among the options provided, baked chicken breast is the lowest in potassium. Cantaloupe is relatively high in potassium. A cup of diced cantaloupe contains about 430 mg of potassium.

Sweet potatoes are known for their high potassium content. A medium-sized sweet potato with skin contains about 542 mg of potassium.

Orange juice also contains a moderate amount of potassium. An 8-ounce serving of orange juice typically contains around 450 mg of potassium.

Chicken breast is naturally low in potassium compared to fruits and vegetables. It contains about 260 mg of potassium per 4-ounce serving.

Therefore, among the given options, the baked chicken breast is the lowest in potassium and would be the most suitable choice for a client with an electrolyte imbalance requiring a low-potassium diet.

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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?

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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?