A nurse is caring for a client who has a new colostomy. The client tells the nurse, "I don't want anyone to see me with this bag." Which of the following responses should the nurse make?

"Many people have colostomies and they live full lives."

"Would it help to speak with someone else who has a colostomy?"

"Why don't you want people to see the colostomy bag?"

"You shouldn't worry, the colostomy is probably only temporary."

Answer and Explanation

The Correct Answer is A

Correct. This response provides reassurance and normalizes the client's experience by emphasizing that having a colostomy does not prevent individuals from leading fulfilling lives. B. Incorrect. While peer support can be beneficial, this response does not directly address the client's concerns or provide immediate reassurance.
C. Incorrect. This response may put the client on the spot and make them feel uncomfortable discussing their feelings. It's important to respect the client's privacy and autonomy in disclosing their reasons for not wanting others to see the colostomy bag.
D. Incorrect. Making assumptions about the temporary nature of the colostomy without medical confirmation may not be accurate and can contribute to false hope or disappointment if the client's colostomy is permanent. It's important to provide honest and accurate information while being supportive of the client's emotional needs.

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Correct Answer is B

Explanation

A. Hemoglobin (Hgb) of 12 g/dL is within the normal range for a pregnant individual and does not typically require notification of the provider.
B. Platelet count of 90,000/mm3 is below the normal range (typically 150,000 to 400,000/mm3) and may indicate thrombocytopenia, which can be associated with conditions such as
preeclampsia or HELLP syndrome. The nurse should notify the provider about this result.

C. Hematocrit of 37% is within the normal range for a pregnant individual and does not typically require notification of the provider.
D. Creatinine level of 0.7 mg/dL is within the normal range and does not typically require notification of the provider.

A. Changing the dressing on a client's IV site B. Suctioning a client's new tracheostomy C. Evaluating a client's risk for developing pressure injuries D. Administering a large-volume enema to a client

Correct Answer is A

Explanation

A (Correct): Changing the dressing on a client’s IV site is a task that can be safely delegated to assistive personnel (AP). It is a routine procedure that does not require complex nursing judgment. AP can be trained to perform this task under the supervision of a nurse.
B: Suctioning a client’s new tracheostomy involves assessing the patient’s airway, monitoring for complications, and making clinical decisions. This task requires nursing expertise and should not be delegated to AP.
C: Evaluating a client’s risk for developing pressure injuries involves assessing skin integrity, mobility, and other factors. This assessment requires nursing knowledge and clinical judgment, making it inappropriate for delegation to AP.
D: Administering a large-volume enema involves assessing the patient’s condition, considering contraindications, and monitoring for adverse effects. This task requires nursing judgment and should not be delegated toUAP.

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A nurse is caring for a client who has a new colostomy. The client tells the nurse, "I don't want anyone to see me with this bag." Which of the following responses should the nurse make?

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