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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Holding an object away from the body may increase the strain on the back muscles and increase the risk of injury.
B. Tightening the abdominal muscles helps provide support for the back and reduces the risk of injury.
C. Bending at the waist can strain the back muscles and increase the risk of injury. The correct technique is to bend at the knees and hips while keeping the back straight.
D. Keeping legs straight while lifting can increase the strain on the back muscles and increase the risk of injury. The correct technique is to bend at the knees and hips while keeping the back straight.
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
Explanation
A. Despite the client reporting thirst and frequent urination, the client's urine specific gravity of 1.010 is within the normal range (1.005 to 1.030). The above symptoms could be associated with the hyperglycemia.
B. There is no indication of a pneumothorax in the nurse's notes or diagnostic results.
C. The casual glucose level of 300 mg/dL is significantly above the normal range (less than 200 mg/dL), indicating hyperglycemia.
D. The client’s WBC level is elevated, 11,500/mm3 (5,000 to 10,000/mm3) thus indicating an infection.
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