Question 1

In caring for a patient who had a fecal surgical diversion,which nursing intervention is essential?

Accepted Answer

A) Place a pouch over the newly created stoma. 
B) Place a dressing over the stoma. 
C) Wait several days before placing a pouch. 
D) Prepare several pouches in advance. 
A) Place a pouch over the newly created stoma. 
B) Place a dressing over the stoma. 
C) Wait several days before placing a pouch. 
D) Prepare several pouches in advance. A

Question 2

The nurse is caring for a patient who has a urinary diversion.The nurse notices that the patient has a temperature of 102° F and foul-smelling urine.What action should the nurse take?

Accepted Answer

A) Obtain a urine culture from the patient's pouch. 
B) Catheterize the patient to obtain a sterile urine specimen. 
C) Notify the physician. 
D) Realize that these are normal findings. 
A) Obtain a urine culture from the patient's pouch. 
B) Catheterize the patient to obtain a sterile urine specimen. 
C) Notify the physician. 
D) Realize that these are normal findings. C

Question 3

The nurse is caring for a preterm infant in the neonatal intensive care unit who has multiple stomas.Given the uniqueness of infants,which action is essential for the nurse to take?

Accepted Answer

A) Apply an ostomy pouch using standard sealants. 
B) Use a pouch that can accommodate increased amounts of flatus. 
C) Use multiple pouches (one for each stoma). 
D) Be aware that the stoma size will remain the same as the baby grows. 
A) Apply an ostomy pouch using standard sealants. 
B) Use a pouch that can accommodate increased amounts of flatus. 
C) Use multiple pouches (one for each stoma). 
D) Be aware that the stoma size will remain the same as the baby grows. B

Question 4

The nurse is caring for a patient who has an ostomy.The nurse notices that the effluent ranges from a thick liquid to a semi-formed stool.The nurse recognizes that this is indicative of which location?

Accepted Answer

A) Descending colon 
B) Ileal portion of the small-intestine 
C) Sigmoid colon 
D) Transverse or ascending colon 
A) Descending colon 
B) Ileal portion of the small-intestine 
C) Sigmoid colon 
D) Transverse or ascending colon

Question 5

When providing care for a patient with a colostomy or an ileostomy,the nurse recognizes that which is an expected assessment finding?

Accepted Answer

A) A moist,reddish-pink stoma 
B) A dry,purplish stoma 
C) Erythema on the skin around the stoma 
D) No drainage noted from the stoma when washed 
A) A moist,reddish-pink stoma 
B) A dry,purplish stoma 
C) Erythema on the skin around the stoma 
D) No drainage noted from the stoma when washed

Question 6

The nurse is caring for a patient with an ostomy.The nurse notes that the ostomy is putting out watery effluent.The nurse recognizes that this is indicative of which location?

Accepted Answer

A) Descending colon 
B) Sigmoid colon 
C) Ileal portion of the small-intestine 
D) Transverse colon 
A) Descending colon 
B) Sigmoid colon 
C) Ileal portion of the small-intestine 
D) Transverse colon

Question 7

In caring for a patient who has a pouch for a noncontinent urinary diversion,which nursing intervention is essential?

Accepted Answer

A) Empty the pouch when it is one-third to one-half full. 
B) Remove the ureteral stents after 2 days. 
C) Pouch the stoma with the patient sitting up. 
D) Dispose of used pouches in the toilet. 
A) Empty the pouch when it is one-third to one-half full. 
B) Remove the ureteral stents after 2 days. 
C) Pouch the stoma with the patient sitting up. 
D) Dispose of used pouches in the toilet.

Question 8

The nurse is preparing to catheterize a patient who has a urostomy and uses a two-piece pouch system.The nurse should take which action?

Accepted Answer

A) Place the patient in a semi-recumbent position. 
B) Remove both pieces of the pouch system. 
C) Remove the pouch and leave the barrier attached. 
D) Use sterile gloves to remove the system. 
A) Place the patient in a semi-recumbent position. 
B) Remove both pieces of the pouch system. 
C) Remove the pouch and leave the barrier attached. 
D) Use sterile gloves to remove the system.

Question 9

A patient who has a urostomy is being discharged to home.Which instruction will the nurse to provide to the patient?

Accepted Answer

A) Restrict fluid intake to reduce urine output. 
B) Report any mucus in his urine. 
C) Keep unused pouches in the refrigerator. 
D) Shower without covering the pouch. 
A) Restrict fluid intake to reduce urine output. 
B) Report any mucus in his urine. 
C) Keep unused pouches in the refrigerator. 
D) Shower without covering the pouch.

Question 10

An ostomy that is created from a portion of the ileum to form a stoma through which urine can exit the body is called a(n)_____________.

Accepted Answer

urostomy
ileal conduit
A urostomy or ile

Question 11

The nurse has removed the patient's old urostomy pouch and is attempting to measure the stoma opening for placement of a new pouch.Which action should the nurse take next?

Accepted Answer

A) Place the patient in a prone position. 
B) Cleanse the peristomal skin with warm soap and water. 
C) Remove any stents that are in place. 
D) Place rolled gauze at the stoma opening. 
A) Place the patient in a prone position. 
B) Cleanse the peristomal skin with warm soap and water. 
C) Remove any stents that are in place. 
D) Place rolled gauze at the stoma opening.

Question 12

A ______________ is an opening in the large intestine or colon for elimination of fecal material.

Accepted Answer

colostomy
An opening in the la

Question 13

The nurse is caring for a patient who had a colostomy placed 5 days earlier.The nurse notes that the stoma is red and moist.Which action should the nurse take?

Accepted Answer

A) Notify the physician immediately. 
B) Apply pressure. 
C) Document the condition of the stoma. 
D) Change the appliance pouch. 
A) Notify the physician immediately. 
B) Apply pressure. 
C) Document the condition of the stoma. 
D) Change the appliance pouch.

Question 14

When assessing the patient with a noncontinent urinary diversion,the nurse finds that the urine has mucus shreds.Which action should the nurse take?

Accepted Answer

A) Culture any drainage. 
B) Instruct the patient to consume less water. 
C) Document the characteristics of the urine. 
D) Cleanse the stoma with soap and water. 
A) Culture any drainage. 
B) Instruct the patient to consume less water. 
C) Document the characteristics of the urine. 
D) Cleanse the stoma with soap and water.

Question 15

When planning care for a patient who has a colostomy,which intervention is important for the nurse to perform when pouching the colostomy?

Accepted Answer

A) Leave an intact skin barrier in place for 3 to 7 days. 
B) Use soap and water to cleanse the peristomal skin. 
C) Empty the pouch when it is two-thirds full. 
D) Use tape to secure pouches that have minor leaks. 
A) Leave an intact skin barrier in place for 3 to 7 days. 
B) Use soap and water to cleanse the peristomal skin. 
C) Empty the pouch when it is two-thirds full. 
D) Use tape to secure pouches that have minor leaks.

Question 16

The nurse is caring for a patient who will have surgery in the morning to have a colostomy placed.The nurse is aware of the physical and emotional stresses that the patient will experience.These include which of the following? (Select all that apply. )

Accepted Answer

A) Body image changes 
B) Fear of social rejection 
C) Sexual function and intimacy issues 
D) Loss of independence 
E) Heightened immunity 
A) Body image changes 
B) Fear of social rejection 
C) Sexual function and intimacy issues 
D) Loss of independence 
E) Heightened immunity

Question 17

An opening that is in the ileal portion of the small-intestine is an ____________.

Accepted Answer

ileostomy
An opening in the il

Question 18

The output from a urinary or fecal stoma is called the _______________.

Accepted Answer

effluent
The output

Question 19

The opening created into the abdominal wall for fecal or urinary elimination is known as a _______________.

Accepted Answer

stoma
Certain diseases or conditions req

Exam 36: Ostomy Care

In caring for a patient who had a fecal surgical diversion,which nursing intervention is essential?

The nurse is caring for a patient who has a urinary diversion.The nurse notices that the patient has a temperature of 102° F and foul-smelling urine.What action should the nurse take?

The nurse is caring for a preterm infant in the neonatal intensive care unit who has multiple stomas.Given the uniqueness of infants,which action is essential for the nurse to take?

The nurse is caring for a patient who has an ostomy.The nurse notices that the effluent ranges from a thick liquid to a semi-formed stool.The nurse recognizes that this is indicative of which location?

When providing care for a patient with a colostomy or an ileostomy,the nurse recognizes that which is an expected assessment finding?

The nurse is caring for a patient with an ostomy.The nurse notes that the ostomy is putting out watery effluent.The nurse recognizes that this is indicative of which location?

In caring for a patient who has a pouch for a noncontinent urinary diversion,which nursing intervention is essential?

The nurse is preparing to catheterize a patient who has a urostomy and uses a two-piece pouch system.The nurse should take which action?

A patient who has a urostomy is being discharged to home.Which instruction will the nurse to provide to the patient?

An ostomy that is created from a portion of the ileum to form a stoma through which urine can exit the body is called a(n)_____________.

The nurse has removed the patient's old urostomy pouch and is attempting to measure the stoma opening for placement of a new pouch.Which action should the nurse take next?

A ______________ is an opening in the large intestine or colon for elimination of fecal material.

The nurse is caring for a patient who had a colostomy placed 5 days earlier.The nurse notes that the stoma is red and moist.Which action should the nurse take?

When assessing the patient with a noncontinent urinary diversion,the nurse finds that the urine has mucus shreds.Which action should the nurse take?

When planning care for a patient who has a colostomy,which intervention is important for the nurse to perform when pouching the colostomy?

The nurse is caring for a patient who will have surgery in the morning to have a colostomy placed.The nurse is aware of the physical and emotional stresses that the patient will experience.These include which of the following? (Select all that apply. )

An opening that is in the ileal portion of the small-intestine is an ____________.

The output from a urinary or fecal stoma is called the _______________.

The opening created into the abdominal wall for fecal or urinary elimination is known as a _______________.

Using Evidence in Practice

Admitting, Transfer, and Discharge

Communication and Collaboration

Documentation and Informatics

Vital Signs

Health Assessment

Specimen Collection

Diagnostic Procedures

Medical Asepsis

Sterile Technique

Safe Patient Handling, Transfer, and Positioning

Exercise Mobility

Support Surfaces and Special Beds

Patient Safety

Disaster Preparedness

Pain Management

Palliative Care

Personal Hygiene and Bed Making

Care of the Eye and Ear

Safe Medication Preparation

Administration of Nonparenteral Medications

Administration of Parenteral Medications

Oxygen Therapy

Performing Chest Physiotherapy

Airway Management

Cardiac Care

Closed Chest Drainage Systems

Emergency Measure for Life Support

Intravenous and Vascular Access Therapy

Blood Therapy

Oral Nutrition

Enteral Nutrition

Parenteral Nutrition

Urinary Elimination

Bowel Elimination and Gastric Intubation

Preoperative and Postoperative Care

Intraoperative Care

Pressure Injury Prevention and Care

Wound Care and Irrigations

Dressings, Bandages, and Binders

Therapeutic Use of Heat and Cold

Home Care Safety

Home Care Teaching

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