The nurse is caring for the stomal area of a client who has a ...

[jessicacav]

The nurse is caring for the stomal area of a client who has a colostomy. Which action is the most appropriate?
 
  1. Apply pressure over the stoma.
  2. Clean the stomal area and pat dry.
  3. Dilate the stoma.
  4. Scrub the stoma.

Question 2

What should the nurse instruct a client prior to administering a cleansing enema?
 
  1. Hold the solution for a short time.
  2. Lie in the left lateral position.
  3. Lie in the right lateral position.
  4. Take fast breaths through the nose.

[Joc]

Answer to Question 1

Correct Answer: 2
Rationale 1: Applying pressure over the stoma may damage the stoma.
Rationale 2: Stomal care includes cleaning the area and patting dry.
Rationale 3: A physician's order is needed if the stoma is to be dilated. Dilating is not routine.
Rationale 4: Scrubbing would cause the stoma to bleed since the area is very vascular.

Answer to Question 2

Correct Answer: 2
Rationale 1: Once the enema is given, the client should hold the solution as long as possible for the best results.
Rationale 2: The client lies in the left lateral positionin order to clean the rectum and sigmoid.
Rationale 3: The client lies in the left lateral position, not the right, in order to clean the rectum and sigmoid.
Rationale 4: The client should take slow deep breaths through the mouth. This will enable the client to hold the solution being given.

[jessicacav]

Excellent

[gcook]

TYSM