A nurse is caring for a client who has colon cancer and is scheduled for a colon resection with a possible colostomy. Before the procedure, the client tells the nurse, "I'm worried about that bag." Which of the following is an appropriate response by the nurse?
"Have you ever known someone who has a colostomy?
"Let's wait until after the surgery to discuss your concerns about your colostomy."
"You are worried about having to wear a colostomy bag?"
"The surgeon will only place the colostomy if it is necessary.”
The Correct Answer is C
The nurse's response demonstrates active listening and empathy, acknowledging the client's concerns and addressing them directly. It allows the client to express their worries and opens up a dialogue for further discussion and support. This response shows that the nurse is attentive to the client's emotions and is ready to provide information and reassurance regarding the colostomy. It also encourages the client to openly discuss their fears and concerns, which can help alleviate anxiety and promote a trusting nurse-client relationship.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Gastric residual refers to the volume of formula or feeding remaining in the stomach after a previous feeding. A gastric residual of 300 mL is considered high and may indicate delayed gastric emptying or impaired gastrointestinal motility.
The other findings mentioned are within normal range or expected in the context of enteral feeding. A blood glucose level of 110 mg/dL is within the acceptable range. Having diarrhea once in a 24-hour period is not unusual and can be attributed to various factors. A weight gain of 0.91 kg (2 lb) in 2 days can be expected due to increased fluid intake with enteral feeding and should be monitored for further trends. However, a high gastric residual is a significant finding that warrants further assessment and intervention.
Correct Answer is C
Explanation
A. Change the tubing set every 72 hr:
Enteral feeding sets should generally be changed every 24 hours to reduce the risk of bacterial contamination.
B. Heat the formula to 40.5° C (105° F):
Enteral formula should be administered at room temperature. Heating it can alter the composition and pose a burn risk to the gastrointestinal mucosa.
C. Aspirate residual volume every 4 hr:
This is recommended to assess tolerance to the feeding and prevent complications like aspiration. Holding feedings may be considered based on facility policy if residuals are high.
D. Flush the tubing with 10 mL of water every 2 hr:
While flushing is necessary to maintain patency, the typical flush is 30 mL every 4 hr (or before and after medications/feedings), unless otherwise specified.
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