A nurse is caring for a client who has a new colostomy. The client refuses to participate in her ostomy care, saying, "I'm not touching that thing." Which of the following actions should the nurse take?

Tell the client that it is safe to touch her ostomy.

Request that someone from the client's family participate in the care.

Ask the client to explain her feelings.

Explain why her participation is important.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Telling the client that it is safe to touch her ostomy may not address the client's concerns or fears.

B. Requesting that someone from the client's family participate in the care may not address the client's concerns or fears.

C. Asking the client to explain her feelings allows the nurse to understand the client's concerns or fears and address them appropriately.

D. Explaining why her participation is important may not address the client's concerns or fears.

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Correct Answer is C,A,B,D,E

Explanation

A. Opening the outside cover of the sterile kit and removing the dust cover exposes the sterile supplies within the kit.
B. Grasping the outermost flap of the sterile kit while opening away from the body helps maintain the sterility of the contents within the kit.

C. Preparing a dry work surface above the waist level ensures that the sterile field is established at a proper height and that the nurse's hands are at the appropriate level for working within the sterile field.
D. Opening the innermost lower flap of the sterile kit while standing away from the sterile field allows the nurse to access the sterile supplies without contaminating the sterile field.
E. Opening each side flap of the sterile kit individually while pulling to the side further establishes the sterile field and provides access to the sterile supplies.

A. Avoid the use of facial gestures during the instructions. B. Determine the client's ability to use a communication board. C. Speak with a loud voice while providing the information. D. Provide the teaching without expecting the client to respond.

Correct Answer is B

Explanation

Rationale:

A. Avoiding the use of facial gestures during the instructions may not be effective for a client with expressive aphasia.

B. Determining the client's ability to use a communication board is appropriate because it helps the nurse understand how the client communicates.

C. Speaking with a loud voice while providing the information may not be effective for a client with expressive aphasia.

D. Providing the teaching without expecting the client to respond may not be effective for a client with expressive aphasia.

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A nurse is caring for a client who has a new colostomy. The client refuses to participate in her ostomy care, saying, "I'm not touching that thing." Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

50. A nurse is preparing to set up a sterile field to change a sterile dressing on a client's abdominal wound. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps)

Correct Answer is C,A,B,D,E

Explanation

A nurse is preparing to reinforce teaching with a client who has expressive aphasia. Which of the following actions should the nurse plan to take?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a group of newly licensed nurses regarding client confidentiality. In which of the following situations can the nurse disclose health information without the client's written consent?

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A nurse is caring for a client who has a new colostomy. The client refuses to participate in her ostomy care, saying, "I'm not touching that thing." Which of the following actions should the nurse take?

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