You have gathered all needed supplies, and d.s. is as comfortable as possible. You begin the pouchingchange. Using the adhesive remover, with the push-pull method, you gently remove the wafer
As you lift the wafer, you note that the peristomal skin has severe erythema directly encircling the stoma. There is
denudation (partial-thickness breakdown) at the medial stoma-skin edge.
How should the skin around the stoma look?
The skin around the stoma should look like normal skin. If redness is present, always check the
back of the removed wafer. If it has "melted" away, leaving exposed skin, the patient might need an
additional barrier, either with paste, ring, or convexity. If there is stool under a portion of the wafer,
there might be an abdominal crease or fold, causing a track for feces to travel under.
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A client is having surgery. The circulating nurse notes the client's oxygen saturation is 90% and the heart rate is 110 beats/min. What action by the nurse is best?
a. Assess the client's end-tidal carbon dioxide level. b. Document the findings in the client's chart. c. Inform the anesthesia provider of these values. d. Prepare to administer dantrolene sodium (Dantrium).
In examining a peripheral IV site, the nurse observes a red streak along the length of the vein, and the vein feels hard and cordlike. What action by the nurse takes priority?
a. Applying continuous heat b. Continuing to monitor site c. Elevating the extremity d. Removing the catheter
Which of the following is NOT a correct guideline for performing R.O.M. exercises?
A) If the patient is able to move body parts, encourage them to do so. B) Do not exercise body parts farther than they can go, or to a point of pain. C) Exercise all joints as ordered regardless of any redness, swelling, or pain. D) Follow a logical sequence.
Collecting saliva or spit from the mouth is taking a sputum specimen
Indicate whether the statement is true or false.