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 D

Explanation

A. Clamp the tube for 30 min every 8 hr: Clamping a chest tube increases the risk of tension pneumothorax and is contraindicated unless ordered by a provider.
B. Pin the tubing to the client's bed sheets: Pinning can cause disconnection or kinking of the tubing, leading to drainage issues.
C. Monitor for at least 150 mL of drainage every hour: Drainage greater than 100 mL/hour, especially after the first hour, should be reported as it may indicate hemorrhage.
D. Replace the unit when the drainage chamber is full. A full drainage chamber must be replaced to ensure the system functions properly and prevents complications like backflow.

A. Apply pressure to the venipuncture site with sterile gauze. B. Perform hand hygiene. C. Clamp the IV tubing. D. Withdraw the catheter from the client's vein. E. Remove the dressing and tape from the venipuncture site.

Correct Answer is B,E,C,A,D

Explanation

Correct order:

Perform hand hygiene.
Remove the dressing and tape from the venipuncture site.
Clamp the IV tubing.
Apply pressure to the venipuncture site with sterile gauze.
Withdraw the catheter from the client's vein.

Rationale:

Hand hygiene is the first step to prevent infection before touching any equipment or the client.
Removing the dressing and tape is done after hand hygiene to expose the IV insertion site, preparing it for removal.
Clamping the IV tubing helps stop the infusion and prevents blood from flowing out when the catheter is removed.
Applying pressure with sterile gauze helps to prevent bleeding and hematoma formation after the catheter is removed.
Withdrawing the catheter should be the final step to complete the procedure.

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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 has a closed-chest tube drainage system. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is preparing to discontinue a client's intravenous infusion. Identify the sequence the nurse should follow to remove the IV catheter. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is B,E,C,A,D

Explanation

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