A patient with a colostomy says, “My pouch blows up like a balloon when I pass gas.”. What is an appropriate response by the nurse?
“Empty the gas like you would if the pouch was full of stool.”.
“Peel back a tiny corner of the skin barrier to allow gas to escape.”.
“Make a tiny pinhole in the top of the pouch to let air out.”.
“Remove the pouch and put on a new one when it gets too full of gas.”. .
The Correct Answer is B
Choice A rationale
While emptying the gas from the pouch like you would if the pouch was full of stool might seem like a logical solution, it is not the most appropriate response. This could potentially lead to messiness and odor, which could cause embarrassment and discomfort for the patient.
Choice B rationale
Peeling back a tiny corner of the skin barrier to allow gas to escape is the most appropriate response. This allows the gas to be released in a controlled manner, reducing the risk of the pouch becoming too full and uncomfortable for the patient. It also minimizes the risk of odor and messiness.
Choice C rationale
Making a tiny pinhole in the top of the pouch to let air out is not recommended. This could potentially lead to leakage of stool, causing messiness and odor. It could also damage the pouch, requiring it to be replaced more frequently.
Choice D rationale
Removing the pouch and putting on a new one when it gets too full of gas is not the most appropriate response. This could be inconvenient for the patient and could potentially lead to skin irritation from frequent changes. It also does not address the issue of the pouch filling with gas.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["167"]
Explanation
To calculate the rate for the infusion pump, you would divide the total volume by the total time, then multiply by the drop factor. Here’s how you can do it: Step 1 is: Calculate the total volume in mL, which is 1000 mL.
Step 2 is: Calculate the total time in minutes. Since there are 60 minutes in an hour, 2 hours is 120 minutes.
Step 3 is: Divide the total volume by the total time. So, 1000 mL ÷ 120 min = 8.33 mL/min.
Step 4 is: Multiply the result by the drop factor. If we assume a standard drop factor of 20 drops/mL, then (8.33 mL/min) × 20 drops/mL = 166.67 drops/min. So, the nurse should set the infusion pump to approximately 167 drops per minute. Vital signsVital signs Explore
Correct Answer is B
Explanation
Choice A rationale
Pressing down on the orbital area of the eye is not typically used as it can cause injury to the eye.
Choice B rationale
Pinching the trapezius muscle is a common method used to elicit a response from a painful stimulus in an unresponsive patient. It is considered safe and effective.
Choice C rationale
Using a 25 gauge needle to elicit a response is not typically recommended as it can cause unnecessary harm to the patient.
Choice D rationale
Eliciting a reflex with a reflex hammer is not typically used to assess responsiveness to painful stimuli. Reflex hammers are primarily used to test reflexes, not responsiveness.
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