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.

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Correct Answer is C

Explanation

Choice A rationale
A DNR prescription does not mean that the patient will only receive pain medication for their treatments. A DNR order simply means that if the patient’s heart stops beating or they stop breathing, medical staff will not attempt resuscitation3.
Choice B rationale
A DNR prescription does not necessarily limit a patient’s current treatment regimen. It only specifies that CPR will not be performed in the event of cardiac or respiratory arrest. Other treatments can still be provided based on the patient’s wishes and the medical team’s recommendations3.
Choice C rationale
A DNR prescription allows a patient to continue with their current treatment regimen. The DNR order only comes into effect if the patient’s heart stops or they stop breathing3.
Choice D rationale
While a DNR prescription may limit the ability to receive invasive procedures in the event of cardiac or respiratory arrest, it does not limit other forms of treatment. The patient can still receive treatments that align with their goals of care3.

A. Fatigue B. Pain C. Fever D. Stridor

Correct Answer is D

Explanation

Choice A rationale
While fatigue is a common symptom of Hodgkin’s disease, it is not the most urgent symptom to address when there is significant cervical lymph node enlargement.
Choice B rationale
Pain can be a symptom of Hodgkin’s disease, but it is not the most urgent symptom to address in this case.
Choice C rationale
Fever can be a symptom of Hodgkin’s disease, but it is not the most urgent symptom to address in this case.
Choice D rationale
Stridor is a high-pitched, wheezing sound caused by disrupted airflow. Stridor may indicate a serious condition affecting the throat or larynx (voice box). With significant cervical lymph node enlargement, the lymph nodes may be pressing on the airway, causing stridor. This is a medical emergency and should be addressed first.

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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 client with a terminal illness asks the nurse, “If I have a DNR prescription, does that mean I will no longer receive any treatment for my condition?” Which of the following statements should the nurse provide to explain a DNR prescription?

Correct Answer is C

Explanation

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?

Correct Answer is D

Explanation

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