ATI PN Fundamentals of Nursing 2020 with NGN Exam 2
ATI PN Fundamentals of Nursing 2020 with NGN Exam 2 ( 49 Questions)
A nurse is reinforcing teaching with a client who has an ostomy. Which of the following statements by the client indicates an understanding of the teaching?
"I will press on the skin barrier for 30 seconds to ensure that it adheres." This statement does not indicate the understanding of the teaching. While pressing on the skin barrier is essential to ensure proper adhesion, the duration of 30 seconds might not be sufficient. It's usually recommended to press and hold the barrier for a longer duration (around a minute) to ensure it adheres securely.
"I will clean around the stoma with a moisturizing soap ."This statement does not indicate the understanding of the teaching. Using a moisturizing soap isn't typically recommended for cleaning around the stoma. Instead, gentle cleansing with mild soap and water or specialized ostomy cleansing products is preferred. Moisturizing soaps may contain ingredients that could irritate the skin or interfere with the adhesion of the barrier.
"I will apply a thin layer of talc powder around the stoma before placing the appliance. "This statement does not indicate the understanding of the teaching. Using talc powder or other powders around the stoma area is generally discouraged. These powders can lead to complications such as clogging the ostomy appliance's filter or causing skin irritation.
"I will cut an opening in the skin barrier that is 1⁄2 inch larger than the stoma." This statement indicates the understanding of the teaching. Ensuring the skin barrier has an opening that is slightly larger than the stoma helps in preventing irritation and ensures a proper fit, allowing the stoma to function without causing damage to the surrounding skin.
Choice A Reason:
"I will press on the skin barrier for 30 seconds to ensure that it adheres." This statement does not indicate the understanding of the teaching. While pressing on the skin barrier is essential to ensure proper adhesion, the duration of 30 seconds might not be sufficient. It's usually recommended to press and hold the barrier for a longer duration (around a minute) to ensure it adheres securely.
Choice B Reason:
"I will clean around the stoma with a moisturizing soap ."This statement does not indicate the understanding of the teaching. Using a moisturizing soap isn't typically recommended for cleaning around the stoma. Instead, gentle cleansing with mild soap and water or specialized ostomy cleansing products is preferred. Moisturizing soaps may contain ingredients that could irritate the skin or interfere with the adhesion of the barrier.
Choice C Reason:
"I will apply a thin layer of talc powder around the stoma before placing the appliance. "This statement does not indicate the understanding of the teaching. Using talc powder or other powders around the stoma area is generally discouraged. These powders can lead to complications such as clogging the ostomy appliance's filter or causing skin irritation.
Choice D Reason:
"I will cut an opening in the skin barrier that is 1⁄2 inch larger than the stoma." This statement indicates the understanding of the teaching. Ensuring the skin barrier has an opening that is slightly larger than the stoma helps in preventing irritation and ensures a proper fit, allowing the stoma to function without causing damage to the surrounding skin.
