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. Loss of bladder tone is an expected age-related change that can lead to increased frequency of urination.
B. Loss of nephrons is related to kidney function and may not directly contribute to nocturia.
C. Reduced blood supply may affect various organs but is not a typical cause of increased nighttime voiding.
D. Loss of kidney tissue may impact kidney function but is not a primary cause of nocturia.
Correct Answer is B
Explanation
A. The right lower quadrant is an anatomical location in the abdomen and is not associated with gas exchange.
B. Gas exchange occurs in the alveoli of the lungs, where oxygen is taken in, and carbon dioxide is expelled.
C. The left ventricle is part of the heart and is involved in pumping oxygenated blood to the body; it is not the site of gas exchange.
D. The trachea is the windpipe that carries air to and from the lungs but is not the specific site of gas exchange.
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