The nurse is caring for an infant with a temporary ileostomy. As part of the nursing plan of care, the nurse monitors for skin breakdown around the stoma
If redness occurs, which action would be most appropriate to promote healing and prevent further skin breakdown? A) Cleaning the area well with a scented diaper wipe
B) Applying a barrier/healing cream or paste on the skin
C) Using a barrier wafer (such as Stomahesive) to attach the appliance
D) Sanitizing the area with an alcohol wipe after each diaper change
B
Response:
The nurse should use barrier/healing cream or paste on the skin around the stoma to promote healing and to prevent further skin breakdown. Diaper wipes that contain fragrance or alcohol can sting if used on non-intact skin and can worsen skin breakdown. The barrier wafer would be helpful but does not address the skin breakdown.
You might also like to view...
A nurse manager has just completed a difficult assignment managing a group that was not cohesive
Which group should the nurse identify as likely having good cohesiveness? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Nurse who each have 7 to 8 years of experience 2. Nurses who work on different units throughout the hospital 3. Staff nurses who are interested in learning about the task of the group 4. Staff nurses who work with one another on a daily basis 5. Staff nurses who are all between 35 and 40 years of age
The families of patients expect their hospitalized member to receive holistic care. What characteristic is an example of provision of holistic care?
a. Providing safety with the side rails up b. Providing only foods and drinks that are to the patient's liking c. Bathing at a time and manner that is spe-cified by the patient d. Including the family in the holistic ap-proach
You are caring for a client during acute substance withdrawal. What is considered the nursing standard of care for monitoring vital signs?
A) Every 1–2 hours during the first 3–4 days of withdrawal B) Every 2–4 hours during the first 3–4 days of withdrawal C) Every 8 hours during the first 3–4 days of withdrawal D) Every shift during the first 3–4 days of withdrawal
Which nursing intervention has the highest priority for a patient with bulimia nervosa?
a. Assist the patient to identify triggers to binge eating. b. Provide corrective consequences for weight loss. c. Assess for signs of impulsive eating. d. Explore patient needs for health teaching.