Author Question: A nurse is preparing to change a client's colostomy pouch. After removing the pouch, which of these ... (Read 102 times)

tatyanajohnson · **on:** Jul 22, 2018

A nurse is preparing to change a client's colostomy pouch. After removing the pouch, which of these steps should the nurse take NEXT?

a. Prepare solution for cleansing the stoma.
b. Measure the stoma to fit the new pouch.
c. Remove gloves, cleanse hands, and apply clean gloves.
d. Place a gauze pad over the stoma while preparing to cleanse it and apply new pouch.

Question 2

How will the nurse document a bladder irrigation on the client's intake and output record?

a. by recording only the amount of irrigant instilled
b. by recording the amount of irrigant instilled and the amount of drainage measured
c. by recording only the amount of drainage
d. by measuring drainage before and after irrigation is completed

canderson530 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

C
When changing a colostomy pouch, apply clean gloves when removing the pouch, remove gloves, cleanse hands, and apply clean gloves before applying new pouch.

Answer to Question 2

B
A three-way catheter is used to perform continuous bladder irrigation to allow inflation of the retention balloon, drainage of urine, and instillation of irrigation solution. The intake and output record is completed by recording the amount of irrigant instilled and the amount of drainage measured.