Quiz 86: Ostomy Care
Perry et al.: Clinical Nursing Skills & Techniques, 9th Edition
Instructor Verified Answers Included
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1. 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
2. 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
3. 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. Document the condition of the stoma.
d. Change the appliance pouch.
4. 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.
5. 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.
6. 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
7. 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.
8. In caring for a patient who has a pouch 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.
9. When assessing the patient with a noncontinent urinary diversion, the nurse finds that the urine has mucus shreds. Which action should the nurse take?
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.
10. 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.
11. 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.
12. 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?
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.
13. 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.
1. 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
1. The opening created into the abdominal wall for fecal or urinary elimination is known as a _______________.
2. The output from a urinary or fecal stoma is called the _______________.
3. A ______________ is an opening in the large intestine or colon for elimination of fecal material.
4. An opening that is in the ileal portion of the small-intestine is an ____________.
5. 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) _____________.