A client with a colostomy tells the nurse about making small pin holes in the drainage bag to help relieve the gas that collects. Which action should the nurse implement?

Tell the client to use larger bags that expand with gas.

Teach the client how to burp the bag to relieve the gas.

Ensure that the pin holes are made at the top of the bag.

Inform the client about bags that have gas release valves.

Answer and Explanation

The Correct Answer is D

A.   Using larger bags might help accommodate the gas more comfortably and reduce the need for making pinholes. However, this solution does not address the immediate issue of gas accumulation and may not be practical for all clients.
B.   "Burping" the bag is a recognized technique for managing gas in colostomy bags. It involves opening the end of the bag slightly to release gas, which helps to prevent the bag from ballooning and causing discomfort. This method is effective and safe, as it is specifically designed to manage gas without compromising the integrity of the bag.
C.   Making pinholes in the colostomy bag is not a recommended practice. Pinholes can lead to leakage and increase the risk of skin irritation or infection. While ensuring the pinholes are at the top might reduce some complications, it does not solve the fundamental issue and poses a risk to the client's health and hygiene.
D.   Colostomy bags equipped with built-in gas release valves are designed specifically to manage gas accumulation safely and effectively. Informing the client about these specialized bags provides a practical solution to the problem of gas buildup and avoids the risks associated with making pinholes.

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Correct Answer is B

Explanation

A. Applying cornstarch or other powders to moist skin can exacerbate dryness and irritation, as powders can absorb moisture but also contribute to a dry skin environment. In general, powders are not recommended for use on already dry or irritated skin, especially for older adults, as they can lead to further skin issues or contribute to fungal infections.
B. Gently applying lotion or moisturizer to the skin after bathing is the most appropriate action. Moisturizers help to rehydrate and lock in moisture, reducing the risk of dry, itchy skin. Applying lotion to damp skin (immediately after bathing) is particularly effective as it helps to seal in the moisture.
C. Adding bath oil to the bath water can be beneficial for moisturizing the skin, as it helps to create a barrier that prevents moisture loss. However, for the client’s specific request about post-bath relief, adding oil to the bath water does not address the immediate need for skin care after bathing.
D. Liquid soap can be gentler on the skin compared to bar soap, which can be drying, especially if it contains harsh ingredients. However, switching from bar soap to liquid soap is a preventive measure and does not provide immediate relief for already dry and itchy skin.

A. The consistency of the prescribed diet. B. Review of current medications. C. Client's ability to chew and swallow. D. The client's respiratory rate and lung sounds.

Correct Answer is C

Explanation

A. Knowing the consistency of the prescribed diet (e.g., pureed, mechanical soft, or regular) is important for planning the feeding process and ensuring that the diet meets the client's needs and restrictions. However, this information is secondary to assessing the client’s ability to safely chew and swallow.
B. While reviewing current medications is important for understanding potential drug interactions, side effects, or dietary restrictions, it is not the most immediate concern before feeding. Medications can influence appetite and digestion, but the priority is ensuring the client can safely handle the food.
C. This is the most critical information to obtain before feeding a debilitated client. Assessing the client's ability to chew and swallow helps prevent complications such as aspiration, choking, or aspiration pneumonia. The nurse should ensure that the client can safely manage the food given to them and that their swallowing mechanisms are functioning adequately.
D. While monitoring the respiratory rate and lung sounds is important for overall health assessment, it is not the immediate priority before starting a feeding session. However, it is important to monitor for signs of aspiration during and after feeding, as compromised swallowing can lead to aspiration pneumonia.

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A client with a colostomy tells the nurse about making small pin holes in the drainage bag to help relieve the gas that collects. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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