NCLEX-PN® ExaminationBasic Care and ComfortMedium
A client with a new colostomy is being taught how to empty their ostomy pouch. The LPN observes the client emptying the pouch into the toilet. Which action by the LPN is most appropriate next?
- ARemind the client to close the pouch clamp securely after emptying.
- BPraise the client for successfully emptying the pouch.
- CInstruct the client to measure the output before discarding.
- DEducate the client on proper hand hygiene after handling the pouch.
Show answer & explanationAnswer & explanation
Correct answer: A. Remind the client to close the pouch clamp securely after emptying.
After emptying the pouch, securely closing the clamp is critical to prevent leakage and maintain hygiene. This step ensures the integrity of the pouching system and prevents skin irritation or infection.
Why the other options are wrong
- B. While positive reinforcement is good, it doesn't address the most critical next step for proper pouch management.
- C. Measuring output is sometimes necessary, but securing the clamp is a more immediate and universal safety step after emptying.
- D. Hand hygiene is important, but it should occur after the pouch is securely closed and the client has completed handling the system.
Ostomy Pouch Emptying
The process of draining stool or urine from an ostomy pouch, typically when it is one-third to one-half full, to prevent leakage and maintain comfort.
- Empty when 1/3 to 1/2 full.
- Close clamp securely after emptying.
- Clean the tail of the pouch.
Memory trick: Empty first, then clamp it tight, to keep everything clean and right.