A nurse is caring for a client who has a newly created colostomy. The client’s partner tells the nurse that the client refuses to look at the stoma. Which of the following actions should the nurse take?

Suggest the client join a support group for people who have colostomies.

Encourage the client and partner to avoid expressing negative feelings about the colostomy.

Instruct the client’s partner to assume care of the colostomy for the client.

Transfer the client to a rehabilitation facility for instruction about self-management of the colostomy.

Answer and Explanation

The Correct Answer is A

Choice A reason: Suggesting a support group helps the client address emotional resistance to the colostomy through peer support. This fosters psychological adjustment, reduces stigma, and promotes self-management by sharing experiences, aligning with evidence-based strategies to improve coping and adaptation in clients with new ostomies.
Choice B reason: Encouraging avoidance of negative feelings dismisses the client’s emotional response, hindering psychological adaptation. Accepting a colostomy requires processing grief and fear. Suppressing emotions delays coping, as psychological adjustment involves acknowledging feelings to integrate the stoma into the client’s self-image effectively.
Choice C reason: Instructing the partner to assume colostomy care undermines the client’s autonomy and delays self-management. Independence in stoma care is critical for psychological and practical adaptation. Dependency may hinder adjustment, as clients need to develop skills to manage their condition independently.
Choice D reason: Transferring to a rehabilitation facility is premature without trying in-hospital education or support groups. Most clients learn stoma care with nursing guidance. Transfer disrupts care continuity and may increase distress, failing to address emotional resistance directly, unlike peer support interventions.

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Correct Answer is C

Explanation

Choice A reason: Catheter placement for a nontunneled central venous access device is typically confirmed by X-ray, not a CT scan, to verify tip placement in the superior vena cava. CT scans are less common due to higher radiation and cost, making this statement inaccurate for standard practice.
Choice B reason: Elevating the head as high as possible during insertion is incorrect, as the Trendelenburg position (head down) is often used to distend veins and reduce air embolism risk. High head elevation could complicate insertion and increase complications, making this instruction inappropriate.
Choice C reason: Flushing the catheter with saline daily maintains patency, preventing clots and ensuring functionality of the nontunneled central venous access device. This is a standard care instruction, reducing infection and occlusion risks, and aligns with evidence-based protocols for central line maintenance, making it correct.
Choice D reason: Lying flat for 24 hours post-procedure is not required for nontunneled central venous catheters. Patients may need brief bed rest (e.g., 30 minutes) to prevent bleeding, but 24 hours is excessive and not evidence-based, making this instruction incorrect and overly restrictive.

A. A single light fixture hangs along the sidewalk to the house. B. The batteries in the smoke alarms are changed annually. C. A small area rug is placed at the front door. D. Electrical cords are secured under furniture.

Correct Answer is B

Explanation

Choice A reason: A single light fixture along the sidewalk provides limited illumination, insufficient for comprehensive safety. Multiple, evenly spaced lights are needed to prevent falls, especially for older adults. Inadequate lighting increases risks of trips or assaults, indicating the client’s understanding of outdoor safety is incomplete and does not fully address home safety needs.
Choice B reason: Changing smoke alarm batteries annually ensures functional alarms, reducing fire-related mortality by 50%. Regular maintenance supports early smoke detection, enabling timely evacuation or response. This action reflects a strong understanding of fire safety, a critical home safety component, making it the best indicator of the client’s safety awareness.
Choice C reason: A small area rug at the front door poses a tripping hazard, particularly for those with mobility issues. Loose rugs can lead to falls, causing injuries like fractures. This finding suggests the client does not fully understand fall prevention, a key aspect of home safety, making it an incorrect indicator of safety awareness.
Choice D reason: Securing electrical cords under furniture risks fire hazards if cords are damaged or pinched, potentially causing electrical shorts. Cords should be secured along walls or with covers to prevent tripping without compromising safety. This indicates a misunderstanding of electrical safety, increasing fire or injury risks, and is not a correct safety measure.

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A nurse is caring for a client who has a newly created colostomy. The client’s partner tells the nurse that the client refuses to look at the stoma. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who is to undergo placement of a nontunneled percutaneous central venous access device. Which of the following statements should the nurse include in the teaching?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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