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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A Alcohol swabs may be too harsh and irritating for the delicate skin around the stoma. Mild soap and water are preferred for cleaning.

Choice B Tap water alone may not be sufficient for removing debris and ensuring proper cleanliness around the stoma. Mild soap and water are preferred for cleaning.

Choice C Iodine may be too harsh and irritating for the peristomal skin. Mild soap and water are preferred for cleaning.

Choice D Mild soap and water are the best choice for cleaning around the colostomy stoma as they effectively remove debris and cleanse the area without being overly harsh on the skin.

A. Blood pressure increases from 110/84 to 118/88 mm Hg. B. Temperature increases from 98.8°F to 99.0°F. C. Pulse rate decreases from 78 to 52 beats/min. D. Respiratory rate increases from 16 to 24 breaths/min.

Correct Answer is C

Explanation

Choice A This change in blood pressure is not alarming and does not require immediate cessation of the procedure.

Choice B A slight increase in temperature is within a normal range and does not indicate an urgent issue related to the stool removal procedure.

Choice C A significant decrease in pulse rate suggests bradycardia, which can be a serious sign and might be caused by the stimulation of the vagus nerve during the procedure. The nurse should stop immediately and take corrective action.

Choice D An increase in respiratory rate may indicate increased anxiety or discomfort, but it is not an immediate cause for stopping the procedure.

View Question and Answer

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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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse knows that the best way to clean around a colostomy stoma is to use the following

Correct Answer is D

Explanation

A nurse is digitally removing stool that is impacted from a patient. The nurse should stop the procedure immediately and take corrective action if the patient's:

Correct Answer is C

Explanation

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