Difficulty: Medium
Average Score: 91%
Simulated
A nurse is caring for a client who has a colostomy. Which of the following actions should the nurse take?
Correct answer
D
Rationale
The correct answer is D: Ensure the pouch is 0.32 cm (1/8 in) larger than the stoma. This is important to prevent irritation and damage to the stoma. If the pouch is too tight, it can cause pressure on the stoma leading to necrosis. If the pouch is too loose, leakage can occur. Applying the pouch while the skin barrier is still damp (choice A) can lead to poor adhesion. Changing the pouch once every 24 hr (choice B) may be too frequent and can irritate the skin. Rubbing the peristomal skin dry after cleaning (choice C) can cause skin irritation.