Author Question: The nurse has completed care with a client who has a new ostomy. What should the nurse document ... (Read 32 times)

HudsonKB16 · **on:** Jul 23, 2018

The nurse has completed care with a client who has a new ostomy. What should the nurse document about the care provided?

1. Report any change in stoma size.
2. Condition of the skin around the stoma.
3. Amount and type of drainage.
4. Client's response to the procedure.
5. Degree of bowel sounds after care provided.

Question 2

A client has received a return-flow enema. What should the nurse document about this procedure?

1. Number of times the solution was changed.
2. Type of solution.
3. Length of time the solution was retained.
4. The amount, color, and consistency of the return.
5. Client relief of flatus and abdominal distention.

huda · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Correct Answer: 1,2,3,4
Rationale 1: After ostomy care, the nurse should document any changes in stoma size.
Rationale 2: After ostomy care, the nurse should document the condition of the skin around the stoma.
Rationale 3: After ostomy care, the nurse should document the amount and type of drainage.
Rationale 4: After ostomy care, the nurse should document the client's response to the procedure.
Rationale 5: The nurse should assess the client's bowel sounds before ostomy care.

Answer to Question 2

Correct Answer: 2,3,4,5
Rationale 1: The nurse does not need to document the number of times the solution was changed.
Rationale 2: For a return-flow enema, the nurse should document the type of solution used.
Rationale 3: For a return-flow enema, the nurse should document the length of time the solution was retained.
Rationale 4: For a return-flow enema, the nurse should document the amount, color, and consistency of the return.
Rationale 5: For a return-flow enema, the nurse should document the client's relief of flatus and abdominal distention.