An enterostomal nurse is teaching a patient how to pouch a ...

[charchew]

An enterostomal nurse is teaching a patient how to pouch a colostomy. The nurse demonstrates in what order? Rank from step A to step D. (Separate letters by a comma and space as follows: A, B, C, D.)
 
  A. Cleanse peristomal skin with warm water.
  B. Apply barrier.
  C. Apply pouch.
  D. Perform hand hygiene.

Question 2

A patient presents to the emergency department diaphoretic and with a fever of 104 F. The nurse recalls that these signs indicate:
 
  A. ADH deficit.
  B. sensible water loss.
  C. insensible water loss.
  D. extracellular overload.

[Chocorrol77]

Answer to Question 1

D, A, B, C

Always begin procedures with hand hygiene. Next, the nurse needs to cleanse the skin to remove old barrier and/or feces. The barrier must be applied to the skin to protect it and to ensure the pouch will fit securely to the skin.

Answer to Question 2

B
With ADH deficit a patient will experience a decrease in urinary output; volume is returned to systemic circulation, diluting the blood and decreasing osmolarity. Insensible water loss is continuous and nonperceptual. Lungs expire about 4000 mL of water daily through changes in respiration. Extracellular overload constitutes excess fluid outside of the cell, either interstitial or intravascular.

[charchew]

Thank you!

[Chocorrol77]

Always glad to help...