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MS III-Ostomy
Chapter 26 Stems
| Question | Answer |
|---|---|
| The nurse explains that an artificial opening into a body cavity is a(n): | Ostomy |
| The colostomy patient is instructed to measure the width of the stomas for the first 6 weeks postoperatively before applying each new pouch because: | The stoma shrinks as it heals, because the swelling goes down |
| A 47-year-old patient who is 3 days postsurgery with a permanent colostomy reports some abdominal discomfort and abdominal rigidity. The assessment that the nurse should report and record is: | Periotonitis. (Increased pulse/resp, increased WBC, abd pain/discomfort, abd rigidity |
| The nurse is aware that many ostomates have an altered self-image, which may cause: | Disturbed body image, which could lead to grief and sexual dysfunction |
| To ensure a good fit of the appliance to avoid leakage, which of the following should the nurse consider for pouch placement? | Special cut for 6-8 weeks, due to swelling. Protective barrier must be obtained to prevent skin breakdown. use adhesive is needed to secure the pouch. |
| In assisting a colostomy patient choose an appropriate diet with little risk of excess gas or diarrhea, the nurse would encourage the patient to choose: | Avoid spicy foods, onions, garlic, some vegetables like cabbage, corn and beans, fish, and high fiber foods (whole grains, fresh fruit and veges) |
| A patient who has had a temporary colostomy to rest his ulcerated bowel says, “I don’t know how I will continue to work at my job with this thing stuck to my stomach.” The nurse’s best response to stimulate communication would be: | Tell me what your concerns are |
| The nurse explains to a preoperative patient that a J-pouch anal anastomosis procedure has the primary advantage of: | Nearly normal bowel evacuation. J-pouch anal anastomosis: Creates a new rectum from the terminal ileum. |
| In postoperative teaching to a ureterotomy patient, the nurse would include information pertaining to: | Clean pouch 1-2 x/day. Blood in urine will clear gradually, should not see mucus, avoid contamination, clean with warm water (mild soap), change q 4-6 days. |
| An ostomate asks the nurse what limitations must be observed in the immediate postoperative period when at home. The most informative information that the nurse can share is: | Avoid direct pressure over stoma, avoid gas-forming foods, avoid heavy-lifting or strenous activities for 3 months, do not irrigate with water in countries in which drinking water is not recommended. |
| The colostomy patient continues to worry about odor. The nurse can help allay those concerns by explaining that odor: | Odor is normal when beging changed or emptied. To minimize odor: Good hygiene, avoid foods that cause gas, odor proof pouches and deodorizers |
| Common surgeries to divert urine may include cutaneous ureterostomy, ileal conduit, and ureteroileostomy. In developing a nursing care plan for any of these patients, the concept that is common to them all is that: | May be temporary or permanent. Stoma on surface. Both have a risk for injured skin integrity |
| The nurse caring for a 2-day postoperative colostomy patient should report immediately if a stoma is assessed as: | Not draining properly, dry, and color other than beefy red (or rose red over time) |
| A baby born without a urinary bladder has a cutaneous ureterostomy with one stoma and a cutaneous ureterostomy has been surgically created. There is one stoma. Discussion with the child’s family regarding care should include which of the following? | Urine drains continously so pouch will need to be worn. Can use belt to hold in place. Change in AM when urine production is low. Blood in urine will clear dradually. Should not see mucus. avoid contamination. |
| The initial assessment of a patient just returned from surgery for creation of an Indiana pouch would include: | Observe for clots and mucus. Monitor drainage from Penrose drain. Assess patency of catheter |
| The patient says, “I hate this yucky paste under my appliance. I think I will just tape it on.” The nurse’s most informative response to this remark would be which of the following? | The paste is a barrier, to protect skin from breakdown |
| The patient comes to the industrial nurse and is frantic because the stoma to the colostomy has prolapsed after 1 year postsurgery. The nurse’s best counsel would be which of the following? | Prolapsed stoma will look frightening, usually isn't serious. Notify dr. if not draining properly |
| A patient is receiving discharge instructions. He shares with the nurse that he intends to do a lot of traveling. Instructions for travel should include which of these points? | Keep supplies in hand-held carrier bag, Include sealable bags, exercise caution with new foods, do not irrigate with water in a country where drinking water is not recommended. |
| The nurse caring for the immediate postoperative patient with an ileal conduit should report and/or intervene for: | Separation of stoma/skin, leakage of anastomosed uretals and intestinal segments, gray/black stoma, retraction, prolapse, hernia, uretal obstruction, infection, crystal formation, calculi |
| The patient asks if rectal suppositories can be used to assist with constipation problems with his colostomy. The nurse clarifies that suppositories: | It can be inserted |
| The nurse identifies an electrolyte imbalance in a preoperative ileostomy patient based on the laboratory values of: | Know normal values. Sodium (135-145), Potassium (3.5-5), Calcium (8.4-10.6), Magnesium (1.3-2.1) Chloride (96-106) |
| The best nursing strategy for encouraging ostomy patient self-care would be to: | Explain what is being done and why. Encourage the patient to take over but do nto force. Have the pt. demonstrate and practice as much as possible before discharge. Be sensitive. |
| The nurse clarifies that the condition that would necessitate an ostomy would be: | After surgery or trauma or when there is severe inflammation or infection. Permanent ostomies are usually necessitated by cancer of the bladder/colon or severe IBD |
| The nurse cautions that some adhesive pouch material used to hold the appliance in place may cause: | Traumatic injuries and allergic responses |
| The most effective way for a nurse to help provide support to the ostomate patient who has ineffective regimen management is to: | First step: Accept the stoma. Look at it. Encourage participation in care but do nto force. Be sensitive. |
| The postoperative colostomy ostomate is at risk for loss of fluid volume and electrolyte imbalance. The assessments that indicate such loss are (select all that apply): | Changes in mental status (confusion/anxiety), changes in nueromuscular status (twitching/tremblin, weakness), poor tissue turgor, edema, dry mucous membranes. |
| The nurse instructs the patient to be diligent in cleaning fecal matter from around the stoma because the fecal matter can cause (select all that apply): | Bacteria, yeast, fungal infections |
| The 1-day postoperative ileostomy patient is concerned about the fact that there has been no drainage from the ileostomy. The nurse reminds the patient that (select all that apply): | Ileostomy drainage begins 24-48 hrs after surgery. Blood/mucus is normal at first |
| The nurse counsels that complications of the continent pouches (Kock and Indiana) may be (select all that apply): | Incontinence, urinary reflex leading to pyelonephritis, difficulty with cathing, bacteriuria |
Created by:
Tarian1023
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