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 ["A","B","C","G"]
Explanation
Choice A rationale
Contact with infected blood or bodily fluids is a major risk factor for Hepatitis B. The virus is present in the blood and bodily fluids of infected individuals and can be transmitted through direct contact.
Choice B rationale
Unprotected sex is a significant risk factor for Hepatitis B. The virus can be transmitted through sexual contact with an infected person.
Choice C rationale
Sharing dirty needles is a well-known risk factor for Hepatitis B. This is particularly a concern among individuals who inject drugs.
Choice D rationale
Sharing eating utensils is not typically a risk factor for Hepatitis B. The virus is not usually transmitted through casual contact or sharing of utensils.
Choice E rationale
Contact with contaminated food or water is not a risk factor for Hepatitis B. The virus is not transmitted through food or water.
Choice F rationale
Exposure to chemicals or toxins is not a risk factor for Hepatitis B. While certain chemicals and toxins can damage the liver, they do not directly cause Hepatitis B3.
Choice G rationale
Contact with infected feces is not typically a risk factor for Hepatitis B. The virus is primarily transmitted through blood and bodily fluids, not fecal matter.
Choice H rationale
Heavy alcohol consumption is not a direct risk factor for Hepatitis B. However, it can contribute to liver damage and complicate the course of the disease if a person is infected.
Correct Answer is D
Explanation
Choice A rationale
Taking two tablets every 15 minutes is not the recommended dosing for nitroglycerin. Overdosing can lead to hypotension and other side effects.
Choice B rationale
While the client should take the nitroglycerin sublingually, taking one tablet every 15 minutes up to 5 times is not the recommended dosing. This could lead to an overdose.
Choice C rationale
Nitroglycerin should be taken sublingually, not orally, for rapid absorption. Taking one tablet orally every hour up to 5 times is not the recommended dosing.
Choice D rationale
This is the correct dosing for nitroglycerin. If chest pain persists after the third dose, the client should seek immediate medical attention.
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