Author Question: The nurse is caring for the stomal area of a client who has a colostomy. Which action is the most ... (Read 23 times)

jessicacav · **on:** Jul 23, 2018

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 · **Reply #1 on:** Jul 23, 2018

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.