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. Infection in the lower leg could cause localized redness, swelling, warmth, and possibly pain. However, the presence of these symptoms alone is not as specific to infection, especially without additional symptoms like fever or purulent discharge.
B. Deep vein thrombosis is a condition where a blood clot forms in a deep vein, commonly in the legs. The symptoms of DVT include swelling (edema), redness (erythema), warmth, and sometimes pain in the affected leg. Given that the client has paresis on one side and is likely less mobile, the risk of DVT increases.
C. A pulmonary embolism occurs when a blood clot (often from the legs) travels to the lungs and causes a blockage. While a pulmonary embolism is a serious complication of DVT, the findings of localized edema and erythema in the leg are more directly associated with DVT itself rather than the secondary complication of a pulmonary embolism.
D. Fat emboli typically occur after fractures or trauma and lead to fat droplets entering the bloodstream and causing blockages in the lungs, brain, or skin. The classic symptoms include respiratory distress, neurological symptoms, and petechial rash.

A. Medical diagnoses. B. Age and gender. C. Developmental stage. D. Functional capacity.

Correct Answer is D

Explanation

A. While medical diagnoses can influence the type of care a client needs, functional capacity is the most important factor when determining the best living environment.
B. Age and gender can be factors to consider, but they are not as important as functional capacity. For example, an older adult with a high level of functional independence may be able to live independently, even if they are elderly.
C. This is not relevant to the decision of where an older adult client should live.
D. The client's functional capacity is the most important factor to consider when determining the best living environment. If the client requires significant assistance with ADLs, a nursing home or assisted living facility may be the most appropriate option.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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