Home » NCLEX » NCLEX-RN » Which of the following basic principles for protecting the skin around her stoma:
A client is being discharged from the hospital today. The discharge teaching for care of her colostomy included which of the following basic principles for protecting the skin around her stoma:
A. Taping a pouch that is leaking
B. Cutting the skin barrier 11/2 inches larger than the stoma
C. Changing the pouch only when leakage occurs
D. Using a skin sealant under pouch adhesives
Correct Answer: D
Explanation/Reference:
Explanation:
(A) When a pouch seal leaks, the pouch should be immediately changed, not taped. Stool held against the skin can quickly result in severe irritation. (B) The skin barrier should be cut only slightly larger than the stoma (one-half inch). (C) The client should be taught to change pouches whenever possible before leakage occurs. (D) When skin sealant is used under the tape, the outermost layer of the epidermis remains intact. When no skin sealant is used, this layer is removed when the tape is removed.
|
Download Printable PDF. VALID exam to help you PASS.
|
 |
