An older adult's perineal skin appears to be dry and thin with mild excoriation. When providing hygiene after a bowel movement, the nurse should
After cleaning the backside, apply a skin protective lotion to protect the skin.
Tape an occlusive moisture barrier pad to the patient's skin.
Massage the skin with deep kneading pressure.
Thoroughly scrub the skin with a washcloth and hypoallergenic soap.
The Correct Answer is A
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale: A pale blue stoma indicates compromised perfusion or necrosis. This is a surgical emergency requiring immediate assessment to prevent tissue death and systemic complications.
Choice B rationale: Continuous drainage may reflect normal output depending on stoma type. It’s not immediately life-threatening and doesn’t require urgent intervention.
Choice C rationale: Fecal contamination is expected with colostomies. While hygiene is important, this does not indicate a critical issue needing priority care.
Choice D rationale: A beefy red, moist stoma is the expected healthy appearance of a functioning colostomy. No intervention is needed.
Correct Answer is C
Explanation
Choice A For an ileostomy, liquid consistency of stool is expected as the output, and it is not an immediate concern.
Choice B Foul odor from the stool is common with ileostomy output, and while it can be unpleasant, it is not an immediate concern.
Choice C This finding should be reported immediately, as it could indicate bleeding from the stoma or intestinal mucosa, which requires prompt evaluation and intervention.
Choice D Continuous output from an ileostomy is normal and expected, so it is not a cause for immediate concern.
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