Coursepoint Module 15 Quiz: Taylor's Clinical Nursing Skills

The nurse is observing a client learning to change the ostomy appliance. Which action by the client would require the nurse to intervene? a) Client traces the same sized opening on the back of the new appliance. b) Client cuts the opening on the new bag 0.5 in (1.25 cm) larger than the stoma size. c) Client applies a skin barrier around the stoma and allows it to dry completely. d) Client measures the ostomy with a measurement guide.

Client cuts the opening on the new bag 0.5 in (1.25 cm) larger than the stoma size. The client's actions are correct, with the exception of cutting the opening 0.5 in (1.25 cm) larger than the stoma size. After measuring the stoma and tracing the opening on the back of the new appliance, the client should cut the opening 0.125 in (0.625 cm) larger than the stoma size. The appliance should fit snugly around the stoma, with only 0.125 in (0.625 cm) of skin visible around the opening. A faceplate opening that is too small can cause trauma to the stoma. If the opening is too large, exposed skin will be irritated by stool. The ostomy should be measured using a measurement guide, then traced on the new appliance. A skin barrier should be applied around the stoma and allowed to dry.

The client asks to help express the small-volume enema solution. Which instructions by the nurse will best facilitate instilling the enema solution completely? a) "Allow gravity to empty the solution from the enema bag then slide the clamp before removal." b) "Squeeze the container completely and then slowly remove the tube from the rectum." c) "Roll the bag toward the buttocks and then keep it rolled while removing it from the rectum." d) "Sit on the toilet and compress the enema until all the fluid is emptied then remove the tube."

"Hold the solution in until the need to defecate is strong." The nurse would instruct the client to hold the enema solution in as long as possible until the need to defecate is very strong (usually 5 to 15 minutes), then ring the bell for assistance to the bathroom. This amount of time usually allows muscle contractions to become sufficient to produce good results. It is unlikely the client will be able to hold the enema for 15 to 20 minutes, and it is unnecessary to do this. Sitting on the toilet while waiting makes it more difficult to hold the solution in. Sitting on the toilet and allowing the fluid to flow out gradually is not going to be helpful, as the client needs to hold it in until the need to defecate is strong.

The nurse is teaching a client how to empty an ostomy appliance. How often would the nurse recommend the appliance be emptied? a) Daily b) after each defecation c) when bag is one-third to one-half full d) every 2 to 3 days

"Roll the bag toward the buttocks and then keep it rolled while removing it from the rectum." The nurse would instruct the client to roll the bag toward the buttocks and keep it rolled while removing it from the rectum. This ensures that all of the fluid is instilled into the rectum and that none of it comes back into the container as it is removed. Squeezing the bag completely does not ensure all of the fluid is instilled, and a vacuum can form if the tube is removed without keeping the bottle compressed. This allows some of the fluid to return into the bottle. Sitting on the toilet and compressing the bag has the same issue as previously, where some fluid can return to the bottle if the bottle is not compressed when removing it. Gravity is used with large-volume enemas by holding the bag about 18 inches above the client.

The nurse is preparing to irrigate a client's NG tube. Which would the nurse include when teaching the client about this procedure? a) "You may feel cold solution going down your throat, but it should not hurt." b) "You may feel a slight burning sensation in the throat." c) "You may experience nausea or vomiting during the flush." d) "You will not experience any unusual sensations with this procedure."

"You may feel cold solution going down your throat, but it should not hurt." The nurse should inform the client that when the tube is flushed with solution, it may feel cold going down the throat, but it will not hurt. The procedure may be a bit uncomfortable, and a sensation of cold may be felt in the throat, but pain, nausea, and vomiting is not normally involved.

The nurse is administering a large-volume enema to treat a client's constipation. After checking the enema device for defects, what should the nurse do next? a) Hang the enema bag on the IV pole. b) Lubricate the rectal tube and insert it into the anus. c) Release clamp and allow solution into tubing to remove air . d) Add the enema solution and any additives to the enema bag.

Add the enema solution and any additives to the enema bag. After checking the enema device the nurse should add the enema solution and any prescribed additives to the enema bag. The next step is to release the clamp and allow fluid to progress through the tube to remove air, then reclamp. The nurse would then hang the bag on the IV pole. Lubricating the rectal tube and inserting it into the anus are steps that follow the preparation of the solution.

The nurse is assisting a client with changing an ostomy appliance. What is the best method of ensuring that the client has understood the procedure and is able to perform it independently? a) Ask the client to repeat each step as it is taught. b) After performing the first appliance change, observe the client performing the next change. c) Have the client watch a video about changing an ostomy appliance. d) Give the client written instructions to review following the teaching, followed by a quiz.

After performing the first appliance change, observe the client performing the next change. A return demonstration of changing the ostomy appliance is the best way to ensure that client teaching has been effective. The nurse would observe the client changing the ostomy appliance during the second change, and offer guidance as needed. The other methods listed can reinforce the teaching, but the nurse must ensure that the client can competently change the appliance prior to discharge.

Which would be most appropriate for the nurse to do when removing a nasogastric (NG) tube? a) Ask the client to take a deep breath and pull out the tube quickly and carefully. b) Ask the client to take short shallow breaths and pull out the tube slowly and carefully. c) Ask the client to turn the head to the side with the chin tilted up when pulling out tube. d) Ask the client to take a deep breath and pull out the tube slowly and carefully.

Ask the client to take a deep breath and pull out the tube quickly and carefully. When pulling out an NG tube, the nurse should ask the client to take a deep breath on the count of three and pull it out quickly and carefully. The client holds his or her breath to prevent accidental aspiration of gastric secretions in the tube. Careful removal minimizes trauma and discomfort for the client.

The nurse is administering a large-volume cleansing enema. After stopping the enema, which instructions should the nurse provide if the client reports severe pain and bloating? a) Breathe in short, shallow breaths. b) Breathe out in short, panting breaths. c) Take some slow, deep breaths. d) Take a deep breath and hold it.

Breathe out in short, panting breaths. If the client experiences severe pain and bloating during enemaadministration, the nurse should stop the enema and instruct the client to take short, panting breaths. This helps to relieve the pain and bloating sensation. Deep breathing helps relax the anal sphincter and facilitates insertion but holding it would not relieve pain and bloating. Short, shallow breaths will not relieve abdominal cramping and bloating sensation.

The nurse is monitoring a client with a colostomy and notices that the ostomy appliance is leaking. What would be the appropriate nursing action in this situation? a) Repair the appliance with tape. b) Notify the health care provider. c) Repair the appliance with adhesive. d) Change the appliance immediately.

Change the appliance immediately. If an ostomy appliance is leaking, the nurse should change the appliance immediately. The health care provider would be notified if the problem persists after changing the appliance. A leaking ostomy appliance can damage the skin around the stoma. The nurse would not attempt to repair it with tape or adhesives because the stool can get trapped between the device and the skin, causing skin breakdown and infection.

The nurse is following the protocol for irrigating a client's nasogastric (NG) tube. Before attaching the syringe to irrigate the tube, which action would be most important for the nurse to do? a) Check tube placement. b) Clamp the tube. c) Have the client lie flat. d) Clear the air vent.

Check tube placement. The nurse needs to check tube placement before instilling any solution into the NG tube to prevent possible aspiration. The tube is clamped intermittently throughout the procedure to prevent air from entering the system. However, if the tube was clamped for irrigating, the tube could not be irrigated. There is no need to clear the air vent. The client should be in an upright position to discourage aspiration if any reflux or vomiting should occur.

The nurse has completed irrigation of a nasogastric tube connected to suction. Which step would the nurse perform following the injection of irrigation solution into a client's nasogastric tube? a) Inject 30 mL of sterile water into the tube. b) Aspirate half the used amount of irrigation solution back into the syringe. c) Connect the unclamped NG tube back to the suction unit. d) Check the placement of the tube by aspirating gastric contents.

Connect the unclamped NG tube back to the suction unit. Following the administration of the irrigation solution into a client's NG tube, the nurse would either connect the NG tube back to the suction unit and unclamp it to withdraw fluid, or aspirate an equal amount of fluid back into the syringe. Alternatively, the nurse can hold the end of the NG tube over an irrigation tray or emesis basin and observe for the return flow of NG drainage.

The health care provider has written a prescription for a client's nasogastric (NG) tube to be removed. Which would the nurse do first? a) Take off the adhesive tape from the client's nose. b) Discontinue the suction. c) Separate the NG tube from the suction tubing. d) Remove the tube from the client gown.

Discontinue the suction. The prescription in which the nurse performs the above steps for removing an NG tube are as follows: discontinue the suction, remove the tube from the client gown, take off the adhesive tape from client's nose, and separate the NG tube from the suction tubing.

In what position would the nurse hold the syringe when instilling irrigation solution into the nasogastric (NG) tube? a) Downward at a 90-degree angle. b) Downward at a 30-degree angle. c) Upward at a 30-degree angle. d) Upward at a 90-degree angle.

Downward at a 90-degree angle. Explanation: After drawing up the irrigation in the syringe, the nurse would hold the syringe upright (90-degree angle) and downward. This allows for a natural flow of the irrigation solution into the NG tube.

The nurse is preparing to empty an open-ended colostomy pouch. Place in order the steps the nurse would take. Use all options. 1. Uncuff the edge of the pouch. 2. Wipe the lower 2 in (5 cm) of the pouch with toilet tissue. 3. Fold the end of the pouch upward like a cuff. 4. Apply the clamp. 5. Empty the contents into a measuring device.

Fold the end of the pouch upward like a cuff. Empty the contents into a measuring device. Wipe the lower 2 in (5 cm) of the pouch with toilet tissue. Uncuff the edge of the pouch. Apply the clamp. Creating a cuff before emptying prevents additional soiling and odor. Emptying comes next using a measuring device. Wiping the lower section removes any additional fecal material, thus decreasing odor problems. The edge of the appliance or pouch should remain clean. Then, the nurse uncuffs the edge of the pouch and, lastly, uses the clamp to secure closure.

Following the removal of a nasogastric NG tube, the nurse should monitor the client for which possible adverse reaction? a) Decreased fluid output. b) Gastric distention. c) Elevated blood pressure. d) Fluid and electrolyte imbalance.

Gastric distention. Following the removal of an NG tube, the nurse would monitor for gastric distention and nausea and vomiting. If the client's abdomen is showing signs of distention, the nurse should notify the health care provider who may prescribe the nurse to replace the NG tube.

While changing the ostomy appliance of a client with a colostomy, the nurse finds significant bleeding from the area around the stoma. What would be the recommended nursing action after notifying the health care provider? a) Wash the area with soap and warm water, allow it to dry, and do not apply the new appliance. b) Allow the bleeding to air-dry thoroughly prior to applying the new appliance. c) Gently pat the area dry and apply the new appliance when the skin is completely dry. d) Use a piece of gauze to apply pressure to the bleeding area; do not apply the new appliance.

Gently pat the area dry and apply the new appliance when the skin is completely dry. If the nurse finds significant bleeding around the stoma, he or she would reassure the client, carefully pat the area dry trying to avoid further trauma to the area, and then apply the new appliance. Applying gauze with pressure to the area would cause further trauma as would washing it with soap and water. Allowing the bleeding to air-dry is not going to help the client, because it will leave a crust over the stoma and further irritate it.

In what position would the nurse place the client prior to removing a nasogastric tube? a) Sitting on the side of the bed. b) In an upright position with the bedrail nearest the nurse down. c) In a flat position with the bedrail nearest the nurse down. d) Flat with the side rails up.

In an upright position with the bedrail nearest the nurse down. The nurse would place the client in an upright position in bed with the rail nearest the nurse down. Appropriate client positioning facilitates comfort for the client and the nurse, ensuring proper body mechanics for the nurse.

The nurse is inserting an enema tube into the anus of the client to treat constipation. How should the nurse insert the tube? a) Insert tube 1 to 2 in (2.5 to 5 cm) and angle toward the naval. b) Insert tube 1 to 2 in (2.5 to 5 cm) and angle toward the bladder . c) Insert tube 3 to 4 in (7.5 to 10 cm) and angle toward the bladder . d) Insert tube 3 to 4 in (7.5 to 10 cm) and angle toward the naval.

Insert tube 3 to 4 in (7.5 to 10 cm) and angle toward the naval. The nurse would insert the enema tube 3 to 4 in (7.5 to 10 cm) and angle toward the naval. The anal canal is about 1 to 2 in (2.5 to 5 cm) long. The tube should be inserted past the external and internal sphincters, but further insertion may damage the intestinal mucous membrane. The suggested angle follows the normal intestinal contour and thus helps prevent perforation of the bowel. Inserting the tube 1 to 2 in (2.5 to 5 cm) is not far enough to pass the internal sphincter. Angling toward the bladder does not follow the normal intestinal contour and could cause perforation of the bowel.

When irrigating a nasogastric tube, the nurse does not get a return after instilling irrigation solution and reconnecting the tube back to the suction unit. What would be the nurse's next step in this situation? a) Instill 30 mL of irrigation solution into the tube and aspirate again. b) Instill 20 mL of water into the tube and aspirate again. c) Instill 20 mL of air into the tube and aspirate again. d) Check the placement of the tube and repeat the procedure.

Instill 20 mL of air into the tube and aspirate again. If the nurse does not get a return after instilling the irrigation solution and reconnecting the tube back to the suction unit, he or she should instill 10 to 20 mL of air into the tube to clear it and aspirate again.

The nurse is getting ready to administer a large-volume cleansing enema to a client undergoing bowel surgery. Which action should the nurse take prior to the procedure? a) Cool the solution to facilitate easy flow. b) Instruct the client to bear down when inserting the tube. c) Lubricate the tip of the rectal tube for easy insertion. d) Introduce the solution intermittently to prevent client cramping.

Lubricate the tip of the rectal tube for easy insertion. The nurse should warm the enema solution, lubricate the tip for easy insertion, and instruct the client to take several deep breaths during administration instead of bearing down. The solution should flow continuously rather than be administered intermittently.

The nurse is not successful in attempting to irrigate a nasogastric tube. The nurse repositions the client and tries to flush the tube with air and water multiple times without success. What action does the nurse take next? a) Document implemented interventions. b) Remove the nasogastric tube. c) Notify the health care provider. d) Replace the nasogastric tube.

Notify the health care provider. If the nasogastric tube is not working properly after correct nursing interventions are attempted, the health care provider is notified to discuss possible complications and further interventions. The nurse may end up removing and replacing the nasogastric tube, but this is not the next action. Documentation occurs after notifying the provider and includes all actions and outcomes of those actions.

The nurse is monitoring a client who had a nasogastric (NG) tube placed postoperatively after abdominal surgery. Which criterion would the nurse use to determine that the tube could be removed? a) Passage of flatus. b) Absent bowel sounds. c) Stable vital signs. d) Loss of appetite.

Passage of flatus. The criteria used to determine that an NG tube can be removed are: return of appetite, return of bowel sounds, and passage of flatus. All of these signs represent a return to normalcy of the gastrointestinal system. Stable vital signs are preferable, but this is not one of the major criteria for tube removal.

When changing a client's ostomy appliance, the nurse finds that feces continue to flow from the stoma, making applying the new appliance difficult. What would be the recommended action when this occurs? a) Wait for the drainage to stop prior to applying the new appliance. b) Clean the stoma with a wet washcloth. c) Apply suction to the stoma prior to applying the new appliance. d) Place a piece of gauze over the stoma to absorb the drainage.

Place a piece of gauze over the stoma to absorb the drainage. When feces continue to flow from the stoma after removing the old appliance, the nurse would place a piece of gauze over the stoma to absorb the drainage while the skin is cleaned and dried. The nurse would then remove the gauze prior to applying the new appliance. Cleaning the stoma and applying suction would not stop the drainage from interfering with the process of applying a new appliance and may damage the stoma. Waiting for the drainage to stop would not allow for the timely application of the new appliance.

The nurse has begun inserting the nasogastric (NG) tube when the client coughs. After assessing that the client can speak without difficulty, what does the nurse do next? a) Insert the tube into the other nostril. b) Assess the client's respiratory status. c) Notify the health care provider. d) Proceed with nasogastric tube placement.

Proceed with nasogastric tube placement. The nurse first ensures that any coughing is related to the gag reflex rather than accidental placement of the NG tube into the airway. When the client breathes and speaks adequately, placement may continue. The nurse has performed the necessary respiratory assessment by ensuring the client can speak well. There is no reason to begin again with the other nostril or to notify the health care provider.

The nurse is irrigating a nasogastric (NG) tube connected to suction for a client undergoing gastric decompression and meets resistance after attaching the irrigation syringe to the NG tube. Which would be most appropriate for the nurse to do first? a) Use 50 mL air instead of irrigation solution. b) Use 20 mL sterile saline instead of irrigation solution. c) Notify the health care provider. d) Reposition the client and try again.

Reposition the client and try again. The nurse who meets resistance when irrigating a nasogastric tube connected to suction should reposition the client first and try again because sometimes the tube can get pushed up against the stomach wall. Repositioning the client can help to remedy this situation. If repositioning fails, the nurse can use 20 mL air instead of irrigation solution to reposition the end of the tube.

Following insertion of a nasogastric tube, the nurse needs to stabilize the tubing for the client. Which action is appropriate for the nurse to take? a) Tape the tubing to the client's sleeve below shoulder level. b) Allow the tubing to hang freely to allow for freedom of movement. c) Secure the tubing with a safety pin to the client's gown at shoulder level. d) Attach the tubing to the bed linens with a rubber band and safety pin.

Secure the tubing with a safety pin to the client's gown at shoulder level. The nurse would secure the tube to the client's gown at the sleeve by using a safety pin, and perhaps a rubber band, ensuring that the air vent is above the level of the stomach. Securing the tube prevents tension and tugging on the tube. Securing the tube in any other place and in any other manner or failure to secure the tube at all can allow the tube to be accidentally removed, possibly requiring reinsertion.

Place in order the steps the nurse should take if a client reports cramping and bloating during enema administration. Use all options. 1. Administer the enema slowly at a height less than 18 in (0.5 m) above the client. 2. Stop administration if the client reports severe cramping and bloating. 3.Encourage the client to take short, panting breaths until the cramping subsides. 4. Discontinue the procedure and notify health care provider if pain occurs.

Stop administration if the client reports severe cramping and bloating. Encourage the client to take short, panting breaths until the cramping subsides. Administer the enema slowly at a height less than 18 in (0.5 m) above the client. Discontinue the procedure and notify health care provider if pain occurs. If the client experiences severe cramping and bloating during enema administration, the nurse should first stop the enema and then instruct the client to take short panting breaths. Next, the nurse should administer the enema slowly at a height less than 18 in (o.5 m). If the pain occurs a second time, the nurse should then discontinue the procedure and contact the health care provider.

The nurse has finished installing a small-volume cleansing enema into a client. What instructions would the nurse give the client following the installation? a) "Hold the solution in for 15 to 20 minutes." b) "Sit on the toilet and allow the solution to flow out gradually ." c) "Sit on the toilet and hold the solution in until unable to do so anymore." d) "Hold the solution in until the need to defecate is strong."

Stop the procedure and monitor client's heart rate. A vagal response occurs when the vagus nerve is simulated, causing parasympathetic stimulation, which triggers a decrease in heart rate, light-headedness, nausea, and dizziness. The best action is to stop the procedure and monitor the client's heart rate and blood pressure. If the heart rate and blood pressure remain low, then the nurse should contact the health care provider. However, contacting the health care provider is not the first action, because the nurse must stop the enema and assess pulse and blood pressure prior to contacting the health care provider. Because this is not a normal response, it is inappropriate to reassure the client that it is normal. Slowing the enema will still stimulate the vagal nerve, and this action does not relieve the problem.

After inserting a nasogastric (NG) tube, what should the nurse do to ensure that the tube is properly placed in the client? a) Obtain an abdominal ultrasound. b) Observe for immediate drainage from the tube. c) Ask about stomach distention and fullness. d) Test the pH of aspirated content.

Test the pH of aspirated content. Current research demonstrates that the use of pH is predictive of correct placement of an NG tube. The pH of gastric contents is acidic (less than 5.5). If the client is taking an acid-inhibiting agent, the range may be 4.0 to 6.0. The pH of intestinal fluid is 7.0 or higher, indicating the tube is beyond the stomach. The pH of respiratory fluid is 6.0 or higher. An x-ray can also be used to check placement of the tube, as well as aspirating the gastric contents and checking them for color and consistency. A feeling of fullness will not confirm tube placement. An ultrasound is not used for confirmation of tube placement.

The nurse has taught a client how to change the ostomy bag. How would the clamp be placed to demonstrate that the client understood the directions? a) The clamp is straight and would be horizontal to the client's body. b) The curve of the clamp would follow the curve of the client's body. c) The curve of the clamp would curve away from the client's body. d) The clamp is straight and would be perpendicular to the client's body.

The curve of the clamp would follow the curve of the client's body. After uncuffing the edge of the pouch, the client should apply the clip or clamp, ensuring that the curve of the clamp follows the curve of the body. Applying the clamp in this way ensures secure closure. If the curve of the clamp curves away from the client's body or is straight, it risks leaking because the clamp would not be secure.

The nurse is collecting supplies to change the ostomy appliance of a client who has an ileostomy following surgery for a tumor. What items would the nurse prepare to wash around the stoma? a) basin of warm water b) sterile saline c) alcohol wipes d) hydrogen peroxide

basin of warm water The nurse would prepare a basin of warm water to wash around the stoma. Thorough cleansing of the skin removes excretions, old adhesive, and skin protectant, which can irritate and damage the skin. Sterile saline is not necessary, because clean technique is being used. Alcohol or hydrogen peroxide could irritate the skin; therefore, using warm water and mild soap is the recommended method for washing around the stoma.

Which nursing assessment takes priority when administering an enema to a client? a) Anxiety b) dizziness c) Headache d) elevated respiratory rate

dizziness When administering an enema to a client, the nurse would assess the client for cramping, dizziness, or pain. The enema may stimulate a vagal response, which increases parasympathetic stimulation. This causes a decrease in the heart rate. Headache and tachypnea are not usually associated with receiving an enema. Anxiety may occur, but dizziness and bradycardia take priority.

A nurse aspirates fluid through a client's nasogastric tube and checks the fluid for color and consistency. Which is a normal finding suggesting correct gastric placement of the tube? a) gray color with particles b) cream color with mucus c) orange color with mucus d) green color with particles

green color with particles Gastric fluid can be green with particles, off white, or brown if old blood is present. Intestinal aspirate tends to look clear or straw-colored to a deep golden-yellow color. Respiratory or tracheobronchial fluid is usually off-white to tan and may be tinged with mucus. No bodily fluids should be orange or gray.

A nurse is administering a small-volume enema to a client to relieve fecal impaction. After initiating this action, the client reports nausea and lightheadedness. The nurse also notes a decrease in the client's heart rate. What should the nurse do first? a) Slow the administration and continue to monitor client response. b) Contact the health care provider immediately. c) Reassure client that this is a normal response to an enema. d) Stop the procedure and monitor client's heart rate.

lying on the left side with the bed flat and the back of the client facing the nurse The nurse would place the client lying on the left side (Sim's position) with the bed flat and the back of the client facing the nurse. This position allows for easy access to the site and facilitates the flow of the solution via gravity into the rectum and colon, optimizing solution retention. Lying in the prone, supine, right side lying positions would not facilitate the flow of the solution via gravity into the rectum and colon.

Which documentation does the nurse complete after inserting a client's nasogastric (NG) tube? a) amount of time it took to complete the procedure b) number of attempts to pass the tubing through the nostril c) client's vital signs and bowel sounds d) measurement of the exposed tube

measurement of the exposed tube The nurse would document the size and type of NG tube that was inserted, the nare used for insertion, the measurement of the exposed tube, the characteristics of the drainage in the tube, and the client's reaction to the procedure. It is not relevant to know how long the NG insertion took or how difficult it was, unless there was trauma. Placing an NG tube is procedure that is not expected to alter the client's vital signs, and it will not immediately alter the client's bowel sounds.

The nurse is teaching a client about emptying an ostomy appliance. How would the nurse instruct the client to hold the appliance when removing the closing clamp? a) Downward b) upward c) perpendicular to the bed d) horizontal to the bed

sitting The nurse would place the client in a comfortable sitting or lying position if the client is in bed. If the client is in the bathroom, a standing or sitting position is used. Either position would allow the client to view the procedure in preparation to learn to perform it independently. Lying flat or sitting upright facilitates smooth application of the appliance. The prone or side-lying position does not allow the client to visualize the procedure.

After measuring from the client's nostril to the ear lobe, how does the nurse continue to measure the length of the nasogastric (NG) tube to be inserted for a client? a) to the tenth intercostal space b) to the abdominal umbilicus c) to the xiphoid process d) to the mammary line

to the xiphoid process The nurse measures the distance to insert the NG tube by placing the tip of the tube at client's nostril and extending to the tip of the ear lobe and then to the tip of the xiphoid process. This measurement ensures that the tube will be long enough to enter the client's stomach without needless coiling. Measuring to the mammary line is too short by about 1 in (2.5 cm) and to the tenth intercostal space or the umbilicus is too long.

After removing the closing clamp on a colostomy appliance, what would be the nurse's next step before emptying the appliance? a) Hold the bag open with the nondominant hand. b) Fold the end of the pouch downward, like an inverted cuff. c) Fold the end of the pouch upward, like a cuff. d) Roll the ends of the bag downward to the filled area.

upward The nurse would instruct the client to hold the ostomy appliance upward when removing the closing clamp to prevent the contents from spilling out. Horizontal or perpendicular to the bed or opening downward would allow the fecal material to spill out of the appliance.

The nurse is emptying an ostomy appliance for a client on bed rest. In what position would the nurse place the client for this procedure? a) prone b) side-lying c) standing d) sitting

when bag is one-third to one-half full The ostomy appliance is emptied when it is one-third to one-half full. If it is allowed to fill up, it may leak or become detached from the skin. After each defecation is usually too frequent, depending on the client's elimination pattern. Daily or every 2 to 3 days is not an appropriate recommendation, because the client's elimination pattern may vary.