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
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Correct Answer is A
Explanation
Placenta previa is a condition where the placenta partially or completely covers the cervix, leading to vaginal bleeding. The bleeding is typically painless and bright red in color. This is an important finding that should be assessed and monitored closely.
A rigid abdomen is not a characteristic finding of placenta previa. It could be a sign of another condition such as placental abruption or uterine rupture, which are separate complications. Fetal movement is not directly related to placenta previa. It is a normal finding and can vary depending on the gestational age and individual fetal patterns.
Placenta previa is not typically associated with persistent uterine contractions. However, it is important to monitor for any signs of preterm labor or other complications that could cause uterine contractions.
Correct Answer is A
Explanation
A.Using visual aids such as pictures, diagrams, or translation cards can help bridge the communication gap between the nurse and the client. This approach ensures better understanding and reduces miscommunication, especially when discussing procedures, medications, or discharge instructions.
B.This is not appropriate because family members may misinterpret medical information, omit details, or add their own opinions. A trained medical interpreter should be used to ensure accurate and confidential communication.
C. Speaking to the client at an increased volume in is not an effective solution for a language barrier. Simply speaking louder will not address the issue of language comprehension. It is important to use appropriate communication strategies, such as seeking a qualified interpreter or using visual aids or gestures to facilitate understanding.
D. Assuming that the client nodding indicates an understanding of the information in is not reliable. Nodding can have different cultural interpretations and may not always indicate comprehension. It is important to use other means of communication to confirm understanding, such as using a professional interpreter or utilizing visual aids.
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