Author Question: When assessing the client with a noncontinent urinary diversion, the nurse finds the peristomal skin ... (Read 26 times)

Hungry! · **on:** Jul 24, 2018

When assessing the client with a noncontinent urinary diversion, the nurse finds the peristomal skin to be reddened. The nurse should first:

A. Culture any drainage
B. Apply an antiseptic cream to the area
C. Make sure that the area remains dry
D. Change the equipment being used for pouching

Question 2

The patient is in the hospital awaiting surgery. When asked to remove her jewelry, the patient asks why she needs to remove her navel ring. What explanation should the nurse provide?

a. The navel ring may impede assessment of the skin.
b. The navel ring may decrease circulation.
c. She may leave it in place if she chooses.
d. The navel ring may cause injury.

quynhmickitran · **Reply #1 on:** Jul 24, 2018

Answer to Question 1

C
C. Keep peristomal skin dry. Determine if client has an allergy to barrier and adhesive or an infection.
A. If there is no urinary output for several hours or output is less than 30 ml/hr, and if urine has foul odor, obtain urine specimen for culture and sensitivity to test for possible infection.
B. Assess for presence of yeast infection around stoma, which causes itching, burning; appears as reddened area with maculopapular rash. Notify physician. Apply medicated cream if ordered.
D. Determine if client has an allergy to barrier and adhesive or an infection. Remeasure stoma before each change to ensure best fit of pouch. Change size of pouch opening as needed to protect skin.

Answer to Question 2

D
Hair appliances and jewelry anywhere on the body may become dislodged and cause injury during positioning and intubation. Navel rings probably would not impede assessment or decrease circulation. Due to the risk of injury if left in place, allowing the patient to leave the ring in place is not an option.