Deck 20: Ostomy Care

Question 1

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

Answer 1

Watery stool

Question 2

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) "I should apply gentle pressure with my hand over the skin barrier to facilitate adherence."
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 need to change the pouch every 3 to 7 days."

Answer 2

"I should apply gentle pressure with my hand over the skin barrier to facilitate adherence."
"I can get a pouch that absorbs gas odors."
"I need to change the pouch every 3 to 7 days."

Question 3

A patient has a new incontinent urostomy because of bladder cancer.The patient asks how he will 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."

Answer 3

"We'll attach a large bedside drainage bag to the outlet of the pouch."

Question 4

The patient notices that the newly formed ileostomy stoma is pinkish red and slightly puffy.Which information should 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.

Question 5

A patient with an ascending colostomy made as a result of abdominal trauma 4 days ago closes his 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 he can 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 his stoma within 1 week.

Question 6

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

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

Question 7

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

A) Use soap and warm water for peristomal cleansing.
B) Leave the pouch in place for 3 to 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

A patient with a urinary diversion requires a sterile urine specimen for culture and sensitivity.Which action should 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 9

A patient is hesitant to look at his stoma 2 days after colostomy surgery.Which is the best response by the nurse to the patient?

A) "I see that you don't want to look at the stoma, but it looks good for a new colostomy."
B) "I'll teach stoma care to each family member before you leave the hospital."
C) "I'll explain everything I do in great detail in case you want to know."
D) "You know you must look at it eventually, so let's look together now."

Question 10

The nurse cares for a female Asian 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 11

2. Feces and urine can flow through a segment of the colon or small intestine and out through the opening (called a stoma)on the abdomen.The output from the stoma is called the ________.

Question 12

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 should the nurse take initially?

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

Question 13

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 14

1. A ___________ is surgically created by transplanting the ureters into a closed-off portion of the intestinal ileum.

Question 15

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 to 7 days.
C) Empty the pouch when it is at least three-fourths full.
D) Change the pouch every other day.

Question 16

You are the home care nurse visiting a patient who is recently discharged home with an ostomy.Which of the following statements requires you 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 keep the new pouches in the bathroom linen closet."