Difficulty: Medium
Average Score: 74%
Simulated
A nurse is completing discharge teaching about ostomy care with a client who has a new stoma. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
Correct answer
B,C,D
Rationale
Correct Answer: B, C, D
Explanation:
B: Cutting the opening of the pouch 1/8 of an inch larger than the stoma ensures a proper fit, preventing leakage and skin irritation.
C: Emptying the pouch when it becomes one-third full prevents leakage and discomfort, maintaining proper hygiene.
D: Placing a piece of gauze over the stoma while changing the pouch prevents infection and protects the stoma from injury.
Incorrect choices:
A: Using povidone-iodine can be too harsh and irritating to the skin around the stoma.
E: Stoma color changes are not typically purple-blue; this could be a sign of poor blood circulation.
Summary:
The correct instructions focus on proper fit, hygiene, and protection of the stoma to ensure optimal ostomy care.
Explanation:
B: Cutting the opening of the pouch 1/8 of an inch larger than the stoma ensures a proper fit, preventing leakage and skin irritation.
C: Emptying the pouch when it becomes one-third full prevents leakage and discomfort, maintaining proper hygiene.
D: Placing a piece of gauze over the stoma while changing the pouch prevents infection and protects the stoma from injury.
Incorrect choices:
A: Using povidone-iodine can be too harsh and irritating to the skin around the stoma.
E: Stoma color changes are not typically purple-blue; this could be a sign of poor blood circulation.
Summary:
The correct instructions focus on proper fit, hygiene, and protection of the stoma to ensure optimal ostomy care.