A nurse is teaching a client who has an ileostomy about the care of their stoma. Which of the following statements by the client indicates an understanding of the teaching?

I should change my stoma pouch 30 minutes after meals.

I should cut my pouch opening 1/8 inch larger than my stoma.

I should clean my stoma with moisturizing soap.

I should expect my stoma to be blistered.

Answer and Explanation

The Correct Answer is B

Choice A reason: Changing the stoma pouch 30 minutes after meals is not recommended, as meal timing does not dictate pouch changes. Pouches are typically changed every 3-7 days or if leaking, to prevent skin irritation. This statement reflects a misunderstanding, as it suggests an incorrect schedule unrelated to stoma care needs.
Choice B reason: Cutting the pouch opening 1/8 inch larger than the stoma ensures a snug fit, preventing leakage while protecting peristomal skin from irritation by digestive enzymes. Proper sizing maintains skin integrity and pouch adherence, supporting effective ostomy management. This statement demonstrates correct understanding of stoma care techniques.
Choice C reason: Cleaning the stoma with moisturizing soap is incorrect, as soaps with oils or fragrances can irritate peristomal skin and impair pouch adhesion. Mild, non-residue soap and water are recommended to maintain skin integrity. This statement indicates a misunderstanding of proper stoma cleaning practices.
Choice D reason: Expecting the stoma to be blistered is incorrect, as a healthy stoma should be pink, moist, and free of irritation. Blistering indicates complications like infection or poor pouch fit. This statement reflects a misunderstanding of normal stoma appearance and care, suggesting potential issues requiring intervention.

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Correct Answer is C

Explanation

Choice A reason: Asking parents to wait outside may increase the preschooler’s anxiety, as parental presence provides comfort. Unless clinically necessary, excluding parents is not ideal, so this action is inappropriate for preparing the child, making it incorrect.
Choice B reason: Teaching deep-breathing to a preschooler is challenging due to their developmental stage, and it may not effectively reduce anxiety for a dressing change. Simpler reassurance is more suitable, so this is less effective, making it incorrect.
Choice C reason: Explaining the procedure in simple terms helps the preschooler understand what to expect, reducing fear and promoting cooperation. This developmentally appropriate approach aligns with pediatric care principles, making it the correct action for preparation.
Choice D reason: Limiting teaching to 20 minutes is impractical for a preschooler, whose attention span is short. Brief, simple explanations are more effective, and prolonged sessions may overwhelm the child, so this is incorrect for preparing them.

A. Place the client upright on a donut-shaped cushion. B. Turn and reposition the client every 15 minutes while sitting. C. Apply a moisture-barrier cream to the affected area. D. Turn and reposition the client every 3 hours while in bed.

Correct Answer is B

Explanation

Choice A rationale: Donut-shaped cushions are contraindicated because they create a ring of high pressure that restricts blood flow to the central area. This can worsen tissue ischemia and accelerate skin breakdown.

Choice B rationale: Clients with paraplegia sitting in a chair should be repositioned every 15 minutes to relieve pressure. Frequent shifts are necessary because sitting exerts higher pressure on the ischial tuberosities than lying down.

Choice C rationale: Moisture-barrier creams are used to protect skin from incontinence or wound drainage. Nonblanchable erythema indicates a stage 1 pressure injury, which requires pressure relief rather than a topical moisture barrier.

Choice D rationale: While in bed, the standard of care is to turn and reposition the client at least every 2 hours. A 3-hour interval is too long and increases the risk of further tissue damage.

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A nurse is teaching a client who has an ileostomy about the care of their stoma. Which of the following statements by the client indicates an understanding of the teaching?

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to perform a dressing change on a preschooler. Which of the following actions should the nurse take to prepare the child for the procedure?

Correct Answer is C

Explanation

A nurse working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of nonblanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan?

Correct Answer is B

Explanation

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