The client is complaining of soreness around the stoma site. The nurse notes proper drainage in the bag, however, the surrounding skin is red, irritated, and moist. How will the nurse interpret this assessment?
This is normal with all new ostomies and the client needs educated on healing.
There is a leak in the appliance and the skin barrier will need replaced.
The ostomy is no longer functioning appropriately, the MD should be called.
The client is overhydrated causing watery stools.
The Correct Answer is B
A. Soreness and redness may occur with new ostomies, but persistent irritation may indicate a problem.
B. Red, irritated, and moist skin around the stoma site suggests a leak in the appliance, and the skin barrier needs replacing.
C. The assessment does not suggest a malfunction in ostomy function but rather a skin integrity issue.
D. Overhydration is not typically associated with skin irritation around the stoma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.5"]
Explanation
To answer this question, we need to use the formula: D/H x Q = X, where D is the desired dose, H is the dose on hand, Q is the quantity of the drug on hand, and X is the amount to administer. In this case, D is 15 mg, H is 30 mg, Q is 1 mL, and X is unknown. Plugging these values into the formula, we get:
15/30 x 1 = X
0.5 = X
Therefore, the nurse will administer 0.5 mL of codeine to the patient every four hours.
Correct Answer is D
Explanation
A. Laxative usage is more likely to cause diarrhea or loose stools rather than rectal pain from distended veins.
B. Paralytic ileus is characterized by a lack of bowel motility and is not associated with distention of veins in the rectum.
C. Diarrhea is unlikely to cause pain related to distention of rectal veins.
D. Hemorrhoids are swollen veins in the rectum and anus, causing pain and discomfort, especially during bowel movements.
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