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 B

Explanation

Choice A rationale
While erythropoietin (Epogen) can help improve symptoms of anemia, such as fatigue, it does not directly increase energy levels.
Choice B rationale
Erythropoietin (Epogen) stimulates the body to produce more of its own red blood cells. This is its primary function and the reason it is used in the treatment of anemia.
Choice C rationale
Erythropoietin (Epogen) does not work like a blood transfusion. While both can increase the number of red blood cells, erythropoietin stimulates the body to produce more of its own red blood cells, while a blood transfusion involves adding red blood cells from a donor.
Choice D rationale
Erythropoietin (Epogen) does not inhibit proteins that attack blood cells. It works by stimulating the production of more red blood cells.

A. “This means that scar tissue formed from the healing of a past abdominal surgery is now constricting the opening in your intestine.”. B. “The most important thing is that now you are here, and it is going to get taken care of.”. C. “I will be happy to go and get you some reading materials about this procedure to explain it further.”. D. “It’s okay. It happens all the time and I’ve seen a lot of clients with this issue.”.

Correct Answer is A

Explanation

Choice A rationale
This statement accurately explains what adhesions are. Adhesions are areas of scar tissue that form between organs or tissues in the abdomen. They often form after surgery and can cause some of these loops to stick together, resulting in abdominal pain and occasionally obstruction (blockages) in the gut. In the context of a small bowel obstruction, adhesions can cause the intestines to twist or kink, similar to how a garden hose can become kinked.
Choice B rationale
While this statement may be intended to reassure the client, it does not provide the client with the information they are seeking about what adhesions are and how they are causing the blockage.
Choice C rationale
Offering to provide reading materials about the procedure does not directly answer the client’s question about what adhesions are. It may also be overwhelming for the client who is already anxious and preparing for emergency surgery.
Choice D rationale
This statement minimizes the client’s concerns and does not provide the necessary information about what adhesions are and how they are causing the blockage.

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 patient with aplastic anemia is scheduled to receive an injection of erythropoietin (Epogen). The patient inquires about the purpose of the injection. How should the nurse respond?

Correct Answer is B

Explanation

A nurse is explaining to a client who is preparing for emergency surgery due to a small bowel obstruction. The client is anxious and doesn’t understand what the surgeon means by “adhesions” causing the blockage. Which of the following statements is the best response from the nurse?

Correct Answer is A

Explanation

A nurse is attending to a client who has suffered a basal skull fracture. During the morning hygiene care, the nurse observes a thin clear drainage coming from the client’s right nostril. What should be the nurse’s immediate action?

A nurse is caring for a patient diagnosed with Hodgkin disease who has significant cervical lymph node enlargement. Which symptom should the nurse address first?

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

The nurse is caring for a patient with chronic liver failure. Which medication order should the nurse querry

Which of the following are risk factors for Hepatitis B? Select all that apply.

A client with a spinal cord injury is at risk for experiencing autonomic dysreflexia. Which of the following manifestations should the nurse carefully monitor the client for?

A nurse is advising a client who is taking furosemide and has a serum potassium level of 3.1 mEq/L. Which food should the nurse recommend the client to incorporate into their daily diet?