A nurse is reinforcing teaching with a client about caring for a new colostomy. Which of the following statements should the nurse make?

"You should scrub the skin around the colostomy when cleaning."

"You can use an adhesive remover when changing the colostomy skin barrier."

"You will need a device to suction stool from the colostomy bag."

"You should empty the colostomy bag when it is three-fourths full."

Answer and Explanation

The Correct Answer is B

b. "You can use an adhesive remover when changing the colostomy skin barrier."

The nurse should inform the client that they can use an adhesive remover when changing the colostomy skin barrier. Adhesive removers are helpful in gently removing the adhesive residue left behind by the previous ostomy appliance. This can make the process of changing the colostomy skin barrier more comfortable for the client and help prevent skin irritation or damage.

Explanation for the other options:

a. "You should scrub the skin around the colostomy when cleaning." Scrubbing the skin around the colostomy can be harsh and may cause skin irritation or damage. It is recommended to clean the peristomal skin gently using mild soap and water, followed by thorough drying.

c. "You will need a device to suction stool from the colostomy bag." Suctioning stool from the colostomy bag is not a routine procedure for colostomy care. Colostomy bags are designed to collect stool, and emptying the bag as needed is the appropriate method of management.

d. "You should empty the colostomy bag when it is three-fourths full." The timing of emptying the colostomy bag may vary for each individual. It is generally recommended to empty the colostomy bag when it is one-third to one-half full to prevent leakage or discomfort. The client should be educated on monitoring the bag and emptying it as necessary based on their own output and comfort level.

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Correct Answer is B

Explanation

b. A decreased level of consciousness and vomiting

Explanation:

When receiving report on four clients, the nurse should first collect data about the client who has a decreased level of consciousness and vomiting. This combination of symptoms suggests a potentially serious condition that requires immediate atention and assessment. It could indicate a neurological or gastrointestinal issue, and further evaluation is necessary to determine the underlying cause and provide appropriate interventions.

Explanation for the other options:

a. Cellulitis accompanied by a low-grade fever:

While cellulitis and a low-grade fever require atention, they are not as immediately critical as a decreased level of consciousness and vomiting. The nurse should prioritize assessing the client with altered consciousness and vomiting due to the potential for more urgent interventions.

c. A pain rating of 7 on a scale from 0 to 10 after receiving analgesia 30 min ago:

Although the client's pain rating of 7 indicates ongoing pain, it is not as immediately critical as a decreased level of consciousness and vomiting. The nurse should first address the client with altered consciousness to determine the cause and provide appropriate interventions before assessing and managing pain in other clients.

d. Type 2 diabetes mellitus and a blood glucose level of 160 mg/dL:

While elevated blood glucose levels in a client with type 2 diabetes require atention and management, they are not as immediately critical as a decreased level of consciousness and vomiting. The nurse should first assess the client with altered consciousness to identify the cause and provide prompt interventions.

In summary, when receiving report on four clients, the nurse should first collect data about the client who has a decreased level of consciousness and vomiting. These symptoms indicate a potentially serious condition requiring immediate assessment and intervention.

A. Encourage the client to gain 2.3 kg (5 lb) per week. B. Monitor the client for 15 min after meals. C. Weigh the client each morning after voiding D. Reinforce teaching about healthy eating during meals

Correct Answer is C

Explanation

C. Weigh the client each morning after voiding: Weighing the client in the morning after voiding is the standard practice for monitoring weight in clients with anorexia nervosa. This helps ensure consistency in the measurement of weight, as fluctuations throughout the day (due to food, fluid intake, etc.) can affect the accuracy of weight assessment.

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A nurse is reinforcing teaching with a client about caring for a new colostomy. Which of the following statements should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse receives report on four clients. The nurse should first collect data about the client who has which of the following?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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