The nurse is caring for an anxious patient who is scheduled for surgery for colostomy placement. While the nurse is talking to the patient, the patient states, "I am so scared." It is a priority for the nurse to focus on addressing the
Cause of the patient's anxiety and fear.
Patient's bowel sounds and presence of gas.
Family's questions about the procedure.
Patient's lung sounds and respiratory rate.
The Correct Answer is A
Choice A Addressing the cause of the patient's anxiety and fear is the priority to provide
emotional support and comfort. The nurse should actively listen to the patient's concerns and offer appropriate reassurance and information.
Choice B While assessing the patient's bowel sounds and gas is important for the overall care, it is not the priority at this moment when the patient is expressing fear and anxiety.
Choice C Addressing the family's questions is important, but the patient's emotional wellbeing should be the immediate focus.
Choice D Respiratory assessment is essential but is not the priority when the patient is expressing fear and anxiety about the upcoming surgery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A : The descending colon is the portion of the colon where stool becomes more formed as water is absorbed, leading to the gradual solidification of stool.
Choice B The transverse colon is responsible for further water absorption, but stool is still relatively less formed compared to the descending colon.
Choice C There is no segment called "oblique colon." It might be a typographical error.
Choice D The ascending colon is the initial part of the colon where undigested food enters, and stool is relatively less formed compared to the descending colon.
Correct Answer is B
Explanation
The correct answer is choice b. Insert the tip of the enema tube into the rectum pointing towards the umbilicus.
Choice A rationale:
Giving the enema while the patient sits on the toilet is incorrect because it can cause discomfort and does not allow for proper administration of the enema solution.
Choice B rationale:
Inserting the tip of the enema tube into the rectum pointing towards the umbilicus is correct because it follows the natural curvature of the rectum and colon, ensuring effective delivery of the solution.
Choice C rationale:
Having the patient lie on the right side is incorrect. The left lateral position is typically recommended for enema administration as it allows the solution to flow more easily into the sigmoid colon and descending colon.
Choice D rationale:
Chilling the water to a temperature between 75°F and 85°F is incorrect. The enema solution should be warmed to body temperature (around 99°F to 106°F) to avoid causing cramping or discomfort.
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