Difficulty: Medium
Average Score: 78%
Simulated
A nurse is caring for a client who has a colostomy. Which of the following actions should the nurse take?
Correct answer
B
Rationale
The correct answer is B: Ensure the pouch is 0.32 cm (1/8 in) larger than the stoma. This is crucial to prevent irritation and pressure on the stoma, allowing proper flow of stool into the pouch. Choice A is incorrect as applying the pouch while the skin barrier is damp can cause skin breakdown. Choice C is incorrect as rubbing the peristomal skin dry can cause irritation. Choice D is incorrect as changing the pouch every 24 hours is unnecessary unless leakage or irritation occurs.