Deck 35: Ostomy Care

Question 1

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)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.

Answer 1

Remove the pouch and leave the barrier attached.

Question 2

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) _____________.

Answer 2

urostomy or ileal conduit
A urostomy or ileal conduit is created from a 6- to 8-inch portion of the intestine that is resected from the ileum.One end of the conduit is sutured closed, and the ureters are implanted through the mucosa.The other end is brought out of the abdominal wall, and a stoma is formed through which urine can exit the body.

Question 3

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

Answer 3

colostomy
An opening in the large intestine or colon is a colostomy, and the fecal effluent will vary in consistency depending on where the opening in the colon is surgically created.

Question 4

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

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.

Question 5

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

Question 6

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?

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.

Question 7

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

Question 8

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?

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

Question 9

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.)

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

Question 10

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

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 11

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

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

Question 12

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?

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

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?

A)Notify the physician immediately.
B)Apply pressure.
C)Note the condition of the stoma in her notes.
D)Change the appliance pouch.

Question 14

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)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 15

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

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 16

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

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.

Question 17

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

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 18

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

Question 19

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

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.