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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?

Many people have colostomies, and they live full lives

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

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

The colostomy is probably only temporary

Answer and Explanation

The Correct Answer is A

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

Explanation:

The correct answer is a. "Many people have colostomies and they live full lives."

When a client expresses concerns or distress regarding their colostomy and not wanting others to see the colostomy bag, it is essential for the nurse to provide support and reassurance. Responding by acknowledging that many people live full lives with colostomies helps normalize the experience and oﬀers hope to the client.

Option b, "Would it help to speak to someone else who has a colostomy?" may be a helpful suggestion, but it should not be the initial response. First, it is important to provide immediate reassurance and support to the client before exploring additional resources or contacts.

Option c, "Why don't you want people to see the colostomy bag?" may be seen as invasive and may put the client on the spot, potentially making them feel uncomfortable or defensive. It is important to create a safe and non-judgmental environment for the client.

Option d, "The colostomy is probably only temporary," assumes information about the client's specific situation that may not be accurate. It is important to avoid making assumptions about the duration or permanence of the colostomy unless the client has shared that information. Providing false reassurances can negatively impact the client's trust and emotional well-being.

By responding with the statement that many people live full lives with colostomies, the nurse oﬀers support, normalizes the client's experience, and promotes a positive outlook for the client's future.

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Correct Answer is C

Explanation

A nurse reviewing the laboratory results of a client who has DKA should identify that the client's ABG results of pH 7.30, PaCO₂ 34 mm Hg and HCO₃ 21 mEq/L indicate metabolic acidosis. Metabolic acidosis is an acid-base imbalance characterized by a low pH (less than 7.35) and a low bicarbonate level (less than 22 mEq/L).

The other options are not correct.

a) Respiratory alkalosisis an acid-base imbalance characterized by a high pH (greater than 7.45) and a low PaCO₂ (less than 35 mm Hg).

b) Metabolic alkalosisis an acid-base imbalance characterized by a high pH (greater than 7.45) and a high bicarbonate level (greater than 26 mEq/L).

d) Respiratory acidosisis an acid-base imbalance characterized by a low pH (less than 7.35) and a high PaCO₂ (greater than 45 mm Hg).

A. Hgb 20 g/dL B. Oxygen saturation 92% C. Productive cough with green sputum D. Chest x-ray shows hyperinﬂation of lungs

Correct Answer is A

Explanation

Answer: A

Rationale:

A) Hgb 20 g/dL:

A hemoglobin level of 20 g/dL is elevated and suggests polycythemia, which can occur in chronic respiratory conditions like COPD due to chronic hypoxia. Elevated hemoglobin levels can increase blood viscosity, leading to complications such as increased risk of thrombosis and cardiovascular stress. This finding indicates a potentially serious issue and should be reported to the healthcare provider immediately to address any underlying causes and manage the client's condition effectively.

B) Oxygen saturation 92%:

An oxygen saturation of 92% is slightly below the typical normal range (95-100%) but is not immediately life-threatening. While it indicates mild hypoxemia, it is a common finding in COPD patients, and the management would typically involve supplemental oxygen or adjustment of therapy. This finding should be monitored but is not the most critical issue to report immediately.

C) Productive cough with green sputum:

A productive cough with green sputum suggests a possible infection or exacerbation of COPD. Although this is an important finding that requires evaluation and possible treatment, it is less critical than an elevated hemoglobin level, which indicates a more acute systemic issue. The green sputum should be reported and managed, but it is not the priority compared to the elevated hemoglobin.

D) Chest x-ray shows hyperinflation of lungs:

Hyperinflation of the lungs is a common radiological finding in COPD due to air trapping. While it is a significant finding, it is generally consistent with the disease's progression and does not indicate an acute problem requiring immediate intervention. Monitoring and managing the underlying COPD are necessary, but this finding is less urgent than the elevated hemoglobin.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the laboratory results of a client who has DKA. The client's ABG results are pH 7.30, PaCO₂ 34 mm Hg and HCO₃ 21 mEq/L. The nurse should identify that these values indicate which of the following acid-base imbalances?

Correct Answer is C

Explanation

A nurse is caring for a client who has COPD. The nurse should identify that which of the following findings is the priority to report?

Correct Answer is A

Explanation

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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?