Deck 21: Ostomy Care

Question 1

A patient with a colostomy made as a result of abdominal trauma 4 days ago closes eyes during stoma care.What patient outcome is most important for the nurse to help the patient achieve?

A) The patient needs no assistance to perform this procedure within a few days.
B) The patient will ask questions about what clothing to wear before discharge.
C) The patient touches the stoma while looking at it within the next 2 days.
D) The patient's family learns how to pouch the stoma within 1 week.

Answer 1

The patient touches the stoma while looking at it within the next 2 days.

Question 2

The home care nurse is visiting a patient who was recently discharged with an ostomy.Which of the following statements require the nurse to provide some additional teaching? (Select all that apply.)

A) "I have been buying sterile gloves to use when changing my pouch."
B) "I have been covering the pouch with saran wrap when I shower."
C) "I empty the pouch directly into the toilet."
D) "I always inspect my skin whenever I change the skin barrier."
E) "I keep the new pouches in the bathroom linen closet."

Answer 2

"I have been buying sterile gloves to use when changing my pouch."
"I have been covering the pouch with saran wrap when I shower."

Question 3

The patient notices that the newly formed ileostomy stoma is pinkish red and slightly puffy.Which information would the nurse include during patient teaching?

A) This is what a new healthy stoma looks like.
B) Any bleeding indicates that a problem is present.
C) Healthy stomas are usually pale pink and flat.
D) There should be very little drainage from the stoma.

Answer 3

This is what a new healthy stoma looks like.

Question 4

The patient's urinary output from a urostomy is 150 mL in the last 4 hours.What action does the nurse take?

A) Document the amount.
B) Notify the physician.
C) Encourage more fluids.
D) Check the skin turgor.

Question 5

A patient with a urostomy requires a sterile urine specimen for culture and sensitivity.Which action will the nurse take to obtain the sterile specimen?

A) Have the patient void into a sterile cup after being cleaned.
B) Collect the specimen from a new urine pouch.
C) Insert a sterile catheter into the urinary stoma.
D) Let urine drip from the stoma into a sterile specimen cup.

Question 6

The nurse is educating a patient about care of a stoma after discharge.Which of the following statements indicate a good level of understanding? (Select all that apply.)

A) "Applying gentle pressure with my hand over the skin barrier helps it stick."
B) "I should also use a skin prep such as a paste or adhesive first."
C) "I can get a pouch that absorbs gas odors."
D) "I can access community resources if supplies are too expensive."
E) "I need to change the pouch every 3-7 days."

Question 7

The home-health nurse pouches an ostomy for a patient with serious financial constraints.What would the nurse recommend to the patient about ostomy care?

A) Use soap and warm water for peristomal cleansing.
B) Leave the pouch in place for 3-7 days.
C) Place several pin holes in the pouch for flatus to escape.
D) Use a firm pouching system on a round, hard abdomen.

Question 8

The nurse is teaching the patient how to size the skin barrier around the stoma.Which instructions does the nurse include?

A) Use the measurement guide for a proper fit.
B) Extend the skin barrier to cover the incisional area.
C) Make a wick from toilet tissue before changing the skin barrier.
D) Trim the skin barrier to fit slightly over the stoma margin.

Question 9

The nurse notices that the patient's stoma is darker than before, purplish in color, and dry.The patient has been taking care of the ostomy independently.What action will the nurse take initially?

A) Document the findings.
B) Ask how the patient is measuring the stoma.
C) Call the health care provider.
D) Rub the stoma to see if it bleeds.

Question 10

The nurse evaluates the effluent from the patient's new ileostomy.What does the nurse expect the effluent to look like immediately after surgery?

A) Formed stool
B) Stool that is like thick liquid
C) Watery stool
D) Semi-formed stool

Question 11

The nurse cares for a patient on the fourth postoperative day after an ileostomy.The patient tells the nurse that she doesn't think she can cope and refuses to look at the ileostomy.What approach by the nurse would be most helpful in this situation?

A) Explore with the patient exactly what her concerns are.
B) Tell her when she can start wearing regular clothing.
C) Tell the patient that most patients have these feelings.
D) Ensure that only female caregivers are assigned to her.

Question 12

The nurse instructs a patient about home colostomy care.What information does the nurse include in patient teaching about caring for the pouch?

A) Empty the pouch at least every 4 hours around-the-clock.
B) Change the pouch every 3-7 days.
C) Empty the pouch when it is at least three-fourths full.
D) Change the pouch every other day.

Question 13

A patient has a new urostomy because of bladder cancer.The patient asks how to manage "all of this urine" at night.Which response by the nurse is best?

A) "You'll get up and empty the bag whenever you wake up at night."
B) "We give you a larger pouch to wear at night to hold the extra urine."
C) "We'll attach a large bedside drainage bag to the outlet of the pouch."
D) "It's really nothing to worry about until you start eating regular meals."