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 C
Explanation
The client needs assistance with morning ADLs, and an occupational therapist is an interprofessional team member who can assist with activities of daily living. Physical therapists focus more on mobility and range of motion exercises, registered dieticians focus on nutrition, and speech-language pathologists work with clients who have difficulty with speech and swallowing.
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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