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 C
Explanation
The presence of edema and coolness around the catheter's insertion site suggests that infiltration may have occurred. Infiltration refers to the unintended leakage of fluid into the surrounding tissues instead of flowing into the vein. It can lead to tissue damage and compromised circulation. Stopping the infusion is the initial priority to prevent further infiltration and minimize potential harm to the client.
Applying a warm compress may be appropriate to promote comfort and circulation in some cases, but it should be done after stopping the infusion and assessing the severity of the infiltration.
Documenting the infiltration is necessary for accurate record-keeping and to communicate the occurrence to the healthcare team. However, it is not the first immediate action required in this situation.
Elevating the arm can help reduce swelling and promote venous return. It can be done after stopping the infusion, but it is not the first action to address the potential infiltration.
Correct Answer is D
Explanation
Explanation
D, Wash hands with soap and water for 20 seconds
Hand hygiene is a critical practice in preventing the transmission of infections in healthcare settings. Here's why the other options are incorrect:
Wearing sterile gloves when in contact with body fluids in (option A) is incorrect because it is important for preventing the transmission of pathogens, but it is not directly related to hand hygiene. Hand hygiene refers to the cleaning of hands to remove pathogens, and sterile gloves provide a barrier to protect the healthcare worker and the patient.
B. Using an alcohol-based cleanser when hands are visibly soiled in (option B) is not recommended. Alcohol-based cleansers are effective in killing many types of germs, but they are not as effective in removing visible dirt, blood, or body fluids. In such cases, it is important to wash hands with soap and water to thoroughly clean them.
Artificial nails should not be worn when performing direct client care in (option C). They can harbor and transmit pathogens and make it more difficult to effectively clean hands. The Centres for Disease Control and Prevention (CDC) recommends that healthcare workers maintain short, clean, and natural nails without the use of artificial nails or nail extensions.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today