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 B

Explanation

B. Herpes simplex is a viral infection that causes skin eruptions or lesions. To promote healing and prevent secondary infections, it is important to keep the affected area clean. Cleansing the skin eruptions with povidone-iodine, an antiseptic solution, can help reduce the risk of infection and promote healing.

The other options are incorrect:

A. Over-the-counter topical ointments are generally not recommended for the treatment of herpes simplex outbreaks. It is best to consult with a healthcare provider for appropriate medication and treatment options.

C.Herpes simplex is a viral infection, and antibiotics are used to treat bacterial infections. Antibiotics are not effective against viral infections like herpes simplex.

D. Placing disposable thermometers in the client's room is not directly related to the management of a herpes simplex outbreak. It is important to focus on interventions specific to the client's condition.

A. Decrease daily fluid intake. B. Withhold the medication if pulse rate is less than 60/min C. Rise slowly from a sitting position to a standing position D. Increase dietary potassium

Correct Answer is C

Explanation

Orthostatic hypotension, which is a sudden drop in blood pressure upon standing, can be a side effect of enalapril and may lead to syncope. Instructing the client to rise slowly from a sitting to a standing position helps minimize the risk of a sudden drop in blood pressure and decreases the chances of syncope occurring.

Decreasing fluid intake is not likely to be the cause of syncope related to enalapril. It is important for clients to maintain adequate hydration, especially if they are experiencing side effects such as orthostatic hypotension.

While a low pulse rate may indicate bradycardia, it is not the primary concern in this situation. Orthostatic hypotension leading to syncope is the main issue, and the client should be instructed to rise slowly to prevent it.

While enalapril is an angiotensin-converting enzyme (ACE) inhibitor that can increase potassium levels in the blood, it is not directly related to syncope. Dietary changes should be made under the guidance of a healthcare provider based on individual needs and blood test results.

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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?

Nursing Test Bank

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A nurse is contributing to the plan of care for a client who is experiencing a herpes simplex outbreak. Which of the following interventions should the nurse recommend?

Correct Answer is B

Explanation

A nurse at an outpatient clinic receives a call from a client who reports experiencing syncope after starting a new prescription for enalapril. Which of the following instructions should the nurse give the client?

Correct Answer is C

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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?