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.”. .

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale

Severe upper abdominal pain can be a sign of gastrointestinal perforation in a patient with peptic ulcer disease. When an ulcer erodes through the wall of the stomach or duodenum, it can cause a perforation, or hole. This is a serious complication that can cause severe pain.

A. Assist the client to sit upright in a chair for 4 hr at a time. B. Expect clear drainage on the spinal dressing. C. Elevate the client’s legs when he is lying on his side. D. Log roll the client every 2 hr.

Correct Answer is D

Explanation

Choice A rationale
Assisting the client to sit upright in a chair for 4 hr at a time is not recommended postoperatively following spinal fusion. This could put undue stress on the surgical site and potentially lead to complications.
Choice B rationale
Expecting clear drainage on the spinal dressing is not accurate. Any drainage from the surgical site should be closely monitored for signs of infection, but clear drainage is not typically expected.
Choice C rationale
Elevating the client’s legs when he is lying on his side is not a specific intervention related to postoperative care following spinal fusion.
Choice D rationale
Log rolling the client every 2 hr is the correct intervention. This technique is used to maintain proper alignment and prevent undue stress on the surgical site.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has peptic ulcer disease. Which of the following findings is a manifestation of gastrointestinal perforation?

Correct Answer is A

Explanation

A nurse is assisting with the plan of care for a client who is 1 day postoperative following spinal fusion. Which of the following interventions should the nurse include in the plan?

Correct Answer is D

Explanation

A patient has severe trauma from an automobile accident. The nurse is checking the gastric pH and is administering Protonix 40 mg IV piggyback two times a day as ordered. This is prophylactic to prevent which of the following?

The nurse is about to administer 1 liter (1000 mL) of 0.9% NS over 2 hours intravenously to a patient in shock. What rate should the nurse set on the infusion pump?

Given the following vital signs, which should the nurse address first in the patient?

A nurse is providing care to multiple patients in a hospital setting. Which patient is at the highest risk for developing hypoglycemia?

A nurse is reinforcing discharge teaching with a client who has pulmonary edema and is about to start taking furosemide. Which of the following instructions should the nurse include?

A nurse is educating a patient newly diagnosed with iron deficiency anemia. Which of the following would be a component of the education?

A nurse is contributing to the plan of care for a client who has urolithiasis. Which of the following interventions should the nurse include in the plan?