A nurse is teaching a client who has an ileostomy about the care of their stoma site. Which of the following statements made by the client indicates the teaching was effective?
"I should clean my stoma with moisturizing soaр."
"I should expect my stoma to be blistered."
"I should cut my pouch opening 1/8 inch larger than my stoma."
"I should change my stoma pouch 30 minutes after meals."
The Correct Answer is C
Rationale:
A. "I should clean my stoma with moisturizing soap.": Moisturizing soaps can leave a residue that interferes with the adhesive seal of the ostomy pouch. The stoma and surrounding skin should be cleaned gently with mild, non-moisturizing soap and water to maintain skin integrity and pouch adhesion.
B. "I should expect my stoma to be blistered.": A healthy stoma should appear pink to red and moist. Blistering indicates trauma, irritation, or infection, which requires assessment and intervention, so this expectation is incorrect.
C. "I should cut my pouch opening 1/8 inch larger than my stoma.": Proper pouch sizing ensures a secure fit around the stoma while protecting the surrounding skin from effluent. Cutting the opening slightly larger than the stoma prevents pressure and irritation.
D. "I should change my stoma pouch 30 minutes after meals.": Ostomy pouch changes should be scheduled when effluent is minimal, typically every 3–7 days or when the pouch is leaking. Timing changes specifically after meals is unnecessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Action: The action stage involves actively implementing strategies to change behavior, such as already using nicotine replacement therapy or abstaining from smoking. Since the client has not yet started quitting but intends to soon, they are not yet in this stage.
B. Contemplation: In this stage, the individual recognizes the need for change but has not yet committed to taking concrete steps. The client requesting a prescription and setting a quit date indicates they have moved beyond contemplation and are preparing for action.
C. Preparation: The preparation stage is characterized by planning to take action within the near future, usually within the next month. The client’s decision to quit within 2 weeks and request a nicotine patch reflects commitment and readiness to initiate behavior change, fitting this stage precisely.
D. Precontemplation: During precontemplation, the individual has no intention of changing behavior and may be unaware of the risks or resistant to advice. This does not apply to the client, who has already expressed motivation and plans to quit smoking soon.
Correct Answer is C
Explanation
Rationale:
A. Call the pharmacist for clarification of the medication contraindications: While the pharmacist can provide medication information, it is the provider’s responsibility to evaluate the appropriateness of the prescription and modify it if needed.
B. Administer the medication as prescribed: Administering amoxicillin to a client allergic to penicillin places the client at risk for an allergic reaction, including anaphylaxis, since both drugs are in the same class.
C. Discuss the prescription with the health care provider: Amoxicillin is a penicillin derivative and contraindicated for clients with penicillin allergies. The nurse should immediately clarify the prescription with the provider before administration to ensure client safety.
D. Place an incident report in the medical record: Incident reports are used after an error or near-miss has occurred, not before a potential error is prevented. They are also never placed in the client’s medical record.
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