A nurse assessing a client with an ostomy appliance documents the ...

[wrbasek0]

A nurse assessing a client with an ostomy appliance documents the condition prolapse in the client chart and notifies the physician. Which of the following statements describes this condition?
 
  A) The peristomal skin is excoriated or irritated because the appliance is cut too large.
  B) The system has leaks or poor adhesion leading to noticeable odor.
  C) The bag continues to come loose and become inverted.
  D) The stoma is protruding into the bag and may become twisted.

Question 2

A nurse is ordered to perform digital removal of stool on a client with stool impaction. Which of the following is an appropriate step in this procedure?
 
  A) Position the client in supine position as dictated by client comfort and condition.
  B) Insert generously lubricated finger gently into the anal canal, pointing away from the umbilicus.
  C) Gently work the finger around and into the hardened mass to break it up and then remove pieces of it.
  D) Instruct the client not to bear down while extracting feces to prevent vagal response.

[Koolkid240]

Answer to Question 1

Ans: D
During prolapse, the stoma is protruding into the bag. The nurse should have the client rest for 30 minutes and, if stoma is not back to normal size within that time, notify the physician. If stoma stays prolapsed, it may twist, resulting in impaired circulation to the stoma.

Answer to Question 2

Ans: C
For digital removal of stool: Position the client on the left side (Sims' position), as dictated by client comfort and condition. Generously lubricate index finger with water-soluble lubricant and insert finger gently into anal canal, pointing toward the umbilicus. Gently work the finger around and into the hardened mass to break it up and then remove pieces of it. Instruct the client to bear down, if possible, while extracting feces, which will ease in removal.

[wrbasek0]

Gracias!

[kilada]

TYSM