A patient with a colostomy says, “My pouch blows up like a balloon when I pass gas.”. What is an appropriate response by the nurse?
“Empty the gas like you would if the pouch was full of stool.”.
“Peel back a tiny corner of the skin barrier to allow gas to escape.”.
“Make a tiny pinhole in the top of the pouch to let air out.”.
“Remove the pouch and put on a new one when it gets too full of gas.”. .
The Correct Answer is B
Choice A rationale
While emptying the gas from the pouch like you would if the pouch was full of stool might seem like a logical solution, it is not the most appropriate response. This could potentially lead to messiness and odor, which could cause embarrassment and discomfort for the patient.
Choice B rationale
Peeling back a tiny corner of the skin barrier to allow gas to escape is the most appropriate response. This allows the gas to be released in a controlled manner, reducing the risk of the pouch becoming too full and uncomfortable for the patient. It also minimizes the risk of odor and messiness.
Choice C rationale
Making a tiny pinhole in the top of the pouch to let air out is not recommended. This could potentially lead to leakage of stool, causing messiness and odor. It could also damage the pouch, requiring it to be replaced more frequently.
Choice D rationale
Removing the pouch and putting on a new one when it gets too full of gas is not the most appropriate response. This could be inconvenient for the patient and could potentially lead to skin irritation from frequent changes. It also does not address the issue of the pouch filling with gas.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While pain management is important in burn care, the first action should be to stop the burning process. Administering IV morphine does not achieve this.
Choice B rationale
Applying ice to a burn can cause vasoconstriction and may increase tissue damage. It is not the first action to stop the burning process.
Choice C rationale
Applying a neutralizing agent is not the first action in chemical burn management. The priority is to remove the chemical from contact with the skin.
Choice D rationale
Removing the patient’s clothing is the first action in burn management. This prevents further contact of the chemical with the skin and stops the burning process.
Correct Answer is B
Explanation
Choice A rationale
Attaching the chest tube system to the foot of the bed is not recommended. This position could potentially cause the system to tip over or become disconnected, which could lead to complications such as pneumothorax or hemothorax.
Choice B rationale
The chest tube system should be placed below the level of the patient’s chest. This allows for gravity-assisted drainage of air and fluid from the thoracic cavity, which is crucial for the patient’s recovery. The system works on a water seal that prevents air or fluid from entering the pleural space. Placing the system below the chest level ensures that the water seal is maintained, preventing backflow of fluid or air into the pleural space.
Choice C rationale
Placing the system along the side of the patient’s knee is not appropriate. This position does not facilitate effective drainage of air and fluid from the thoracic cavity. It could also lead to discomfort and potential dislodgement of the system.
Choice D rationale
Placing the system at the level of the patient’s clavicle is not recommended. This position is too high and could disrupt the water seal, leading to ineffective drainage and potential complications.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.