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 A
Explanation
A. Unsaturated fats, such as those found in olive oil and fatty fish, can be beneficial for heart health and are preferred in a cardiac diet.
B. Trans fats and saturated fats are associated with increased risk of cardiovascular disease and should be limited.
C. Saturated fats, found in animal products and some oils, should be limited in a heart-healthy diet.
D. Hydrogenated fats contain trans fats, which should be minimized in the diet due to their negative impact on cardiovascular health.
Correct Answer is B
Explanation
A. Emptying the collection bag and waiting 30 minutes does not ensure the specimen is sterile.
B. Clamping the tubing and withdrawing urine from the sample port helps obtain a sterile specimen.
C. Collecting urine directly from the urine bag may introduce contaminants and is not considered a sterile technique.
D. Discontinuing the indwelling catheter is not necessary; a sample port is typically available for obtaining a sterile specimen.
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