A nurse is caring for a client who has a new colostomy. The client refuses to participate in her ostomy care, saying, "I'm not touching that thing." Which of the following actions should the nurse take?
Tell the client that it is safe to touch her ostomy.
Request that someone from the client's family participate in the care.
Ask the client to explain her feelings.
Explain why her participation is important.
The Correct Answer is C
Rationale:
A. Telling the client that it is safe to touch her ostomy may not address the client's concerns or fears.
B. Requesting that someone from the client's family participate in the care may not address the client's concerns or fears.
C. Asking the client to explain her feelings allows the nurse to understand the client's concerns or fears and address them appropriately.
D. Explaining why her participation is important may not address the client's concerns or fears.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Ensuring that four fingers fit between the restraint and the client's body is important to prevent injury and discomfort.
B. Applying the belt restraint over the client's gown may lead to slippage and ineffective restraint.
C. Checking the client's skin integrity every 4 hours is important, but it is not specific to the use of a belt restraint.
D. Tying the belt restraint to the side rail of the bed is not appropriate because it can restrict movement and cause injury.
Correct Answer is B
Explanation
Rationale:
A. Allowing sterile forceps to rest in a container of sterile does not affect the sterility of the field.
B. Pouring sterile solution with the bottle held over the field is an inappropriate technique since it breaches the sterility of the field.
C. Placing unnecessary sterile items on the field is not ideal, but it does not indicate contamination of the surgical field.
D. The handle of a pair of sterile scissors resting 5 cm (2 in) from the field's edge does not indicate contamination of the surgical field. The scissors should be placed within easy reach of the nurse but should not touch non-sterile items.
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