A nurse is reinforcing teaching for a client who has a new ascending colostomy. Which of the following comments by the client indicates an understanding of the teaching?
I will irrigate the colostomy every day.
I will notify my doctor if the stoma starts to look purple.
I will no longer be able to eat nuts.
I should expect my stool to be formed.
The Correct Answer is B
I will notify my doctor if the stoma starts to look purple
The comment by the client indicating an understanding of the teaching is option B: "I will notify my doctor if the stoma starts to look purple."
I will irrigate the colostomy every day in (option A) is incorrect. Colostomy irrigation is not necessary for all clients with an ascending colostomy. It is important to individualize the teaching based on the client's specific needs and healthcare provider's instructions. Routine colostomy irrigation may not be required, and the client should follow the healthcare provider's guidance regarding colostomy care.
I will no longer be able to eat nuts in (option C) is incorrect. There are generally no dietary restrictions for clients with an ascending colostomy, unless otherwise advised by their healthcare provider. It is important to provide accurate information about dietary considerations, which may vary based on individual circumstances and healthcare provider recommendations.
I should expect my stool to be formed in (option D) is incorrect. With an ascending colostomy, the stool is typically liquid or semi-liquid as it comes from the ascending colon, which is higher in the gastrointestinal tract. The stool is not expected to be formed. It is important for the client to have appropriate expectations regarding stool consistency to manage their colostomy effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Promoting trust involves actions that build a sense of trust and rapport between the nurse and the client. In this scenario, the nurse recognizes the client's basic need for food and responds to it promptly and compassionately. By interrupting the bath to address the client's hunger, the nurse demonstrates attentiveness and care, which helps establish trust between the nurse and the client.
B. Countertransference refers to the nurse's emotional reaction or response to the client, which may be based on the nurse's personal experiences or unresolved issues. It does not apply to the nurse's action of obtaining a meal for the client.
C. Veracity refers to truthfulness and honesty. While the nurse's action can be seen as honest and caring, it does not specifically relate to the concept of veracity.
D. Boundary crossing refers to a situation where the nurse exceeds the established professional boundaries with the client. In this scenario, the nurse's action of obtaining a meal for the client can be seen as a minor deviation from the routine care but is not considered a significant boundary crossing.
Correct Answer is D
Explanation
Using the overbed trapeze helps the client strengthen their upper body and improve mobility by allowing them to independently move and reposition themselves in bed. This promotes independence in activities of daily living and reduces reliance on nursing assistance.
Cautioning the client to avoid a prone position while in bed is important for preventing pressure ulcers and maintaining proper positioning, but it does not specifically promote independence and mobility.
Keeping a loose, absorbent dressing over the surgical site is important for wound care and infection prevention, but it does not directly promote mobility or independence.
Maintaining abduction of the client's residual limb with a pillow is important to prevent contractures, but it does not directly promote mobility or independence.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today