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    Ati pn comprehensive predictor 2023 proctored exam

    A nurse is contributing to the plan of care for a client who has a new ileostomy. Which of the following actions should the nurse include?

    Explanation & Rationale

    A. Encourage the client to include celery in their diet: Celery is high in fiber and stringy, which can increase the risk of obstruction in a client with a new ileostomy. Clients should avoid foods that can block the stoma until healing is complete and they are accustomed to managing their ostomy. B. Cleanse around the client's stoma with hydrogen peroxide: Hydrogen peroxide can damage healthy skin and tissue around the stoma. The area should be cleansed gently with warm water and mild soap, avoiding harsh or irritating substances to promote skin integrity. C. Cut the skin barrier opening 2.5 cm (1 in) larger than the stoma: The skin barrier opening should be no more than 1/8 inch (about 0.3 cm) larger than the stoma. A larger opening exposes more skin to stoma output, increasing the risk for skin irritation and breakdown. D. Empty the client's pouch when it is halfway full: Emptying the pouch when it is about halfway full prevents the weight from pulling on the seal, reducing the risk of leaks and protecting the skin. It also maintains client comfort and reduces the chance of pouch rupture.

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