A nurse is collecting data from a client who has a newly placed colostomy. Which of the following findings should indicate to the nurse the client has accepted their new altered body image?

Prefers not to look at the stoma site

Participates in performing ostomy care

Denies feelings of sadness about the ostomy

Accepts that sexual activity will decrease

Answer and Explanation

The Correct Answer is B

A. "Prefers not to look at the stoma site.": Avoidance suggests denial or difficulty accepting the body change.
B. "Participates in performing ostomy care." Active participation in care indicates the client is adjusting to their new body image and accepting their altered appearance.
C. "Denies feelings of sadness about the ostomy.": Denial of emotions does not necessarily mean acceptance. Acknowledging and expressing feelings is important for adjustment.
D. "Accepts that sexual activity will decrease.": This statement reflects resignation rather than acceptance. Many clients with a colostomy maintain an active sexual life.

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Correct Answer is A

Explanation

A. The client has an inspiratory stridor. Inspiratory stridor indicates airway obstruction or laryngeal edema, a potentially life-threatening complication following a bronchoscopy that requires immediate intervention.
B. The client reports a sore throat: A sore throat is common after bronchoscopy due to irritation from the scope. This does not require reporting.
C. The client’s sputum has streaks of blood: Small amounts of blood in sputum are expected due to minor mucosal trauma.
D. The client’s temperature is 38.6°C (101.4°F): Mild fever can occur post-procedure due to inflammation but should only be reported if it persists or other infection signs develop.

A. Perform suctioning. B. Instill saline into the tubing. C. Increase the humidification. D. Check the cuff pressure.

Correct Answer is A

Explanation

A. Perform suctioning: Restlessness and crackles in the lungs may indicate retained secretions. Suctioning the tracheostomy can help clear secretions and improve oxygenation.
B. Instill saline into the tubing: Routine instillation of saline is not recommended as it can cause discomfort, dislodge bacteria, or create a risk of aspiration.
C. Increase the humidification: While humidification helps prevent mucus from becoming thick, it does not address the immediate issue of retained secretions causing crackles.
D. Check the cuff pressure: While it is important to ensure appropriate cuff pressure, this is not the primary intervention for resolving restlessness and crackles, which suggest secretion buildup.

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A nurse is collecting data from a client who has a newly placed colostomy. Which of the following findings should indicate to the nurse the client has accepted their new altered body image?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who had a bronchoscopy 12 hr ago. Which of the following findings should the nurse report to the provider?

Correct Answer is A

Explanation

A nurse is caring for a client who has a tracheostomy tube. Upon data collection, the nurse observes the client is restless and hears crackles in the lungs. Which of the following interventions should the nurse take?

Correct Answer is A

Explanation

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