Chapter 35: Ostomy Care Nursing School Test Banks

MULTIPLE CHOICE

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

ANS: C

An opening in the ileal portion of the small intestine is an ileostomy, and the fecal effluent will be watery to thick liquid that will contain some digestive enzymes. A colostomy in the descending or sigmoid colon generally results in a stool similar to that normally passed through the rectum. If the opening is in the transverse or ascending colon, the effluent will vary from thick liquid to semi-formed stool.

DIF: Cognitive Level: Analysis REF: Text reference: p. 866

OBJ: Explain differences in the color and consistency of effluent based on the type of ostomy.

TOP: Position of the Ostomy KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

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

ANS: D

If the opening is in the transverse or ascending colon, the effluent will vary from thick liquid to semi-formed stool. A colostomy in the descending or sigmoid colon generally results in a stool similar to that normally passed through the rectum. An opening in the ileal portion of the small intestine is an ileostomy, and the fecal effluent will be watery to thick liquid that will contain some digestive enzymes.

DIF: Cognitive Level: Analysis REF: Text reference: p. 866

OBJ: Explain differences in the color and consistency of effluent based on the type of ostomy.

TOP: Position of the Ostomy KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

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.

Note the condition of the stoma in her notes.

d.

Change the appliance pouch.

ANS: C

The stoma should be red or pink and moist. After assessment the nurse will note the appearance of the stoma in the patient HER. If it is gray, purple, or black, report this to the charge nurse or physician immediately. Pressure is applied to control active bleeding. The information given in the question does not indicate that there is a need to change the appliance at this time.

DIF: Cognitive Level: Application REF: Text reference: p. 870

OBJ: Describe methods used to maintain the integrity of the peristomal skin.

TOP: Condition of Ostomy KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

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.

ANS: A

Immediately after a fecal surgical diversion, it is necessary to place a pouch over the newly created stoma to contain effluent when the stoma begins to function. The pouch will keep the patient clean and dry, will protect the skin from drainage, and will provide a barrier against odor. Dressings would obstruct the opening and would become saturated with fecal material. Preparing multiple pouches in advance would be counterproductive; in the immediate postoperative period, the stoma may be edematous and the abdomen distended. These symptoms eventually resolve, but during this time, it will be necessary to revise the pouching system to meet the changing size of the stoma and the changes in body contours.

DIF: Cognitive Level: Application REF: Text reference: p. 868

OBJ: Describe methods used to maintain the integrity of the peristomal skin.

TOP: Immediate Postsurgical Care KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

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.

ANS: A

Observe the existing skin barrier and pouch for leakage and length of time in place. The pouch should be changed every 3 to 7 days, not daily. To minimize skin irritation, avoid unnecessary changing of the entire pouching system, but if the effluent is leaking under the wafer, change it, because skin damage from the effluent will cause more skin trauma than will be caused by early removal of the wafer. Cleanse the peristomal skin gently with warm tap water using a washcloth; do not scrub the skin. Pat the skin dry. Avoid soap; it leaves residue on the skin, which interferes with pouch adhesion. Pouches must be emptied when they are one-third to one-half full, because the weight of the pouch may disrupt the seal of the adhesive on the skin. If the ostomy pouch is leaking, change it. Taping or patching it to contain effluent leaves the skin exposed to chemical or enzymatic irritation.

DIF: Cognitive Level: Application REF: Text reference: p. 870

OBJ: Pouch a fecal or urinary diversion. TOP: Pouching a Colostomy or Ileostomy

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

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

ANS: A

Normal findings in a patient with a postoperative ostomy that is healing include a stoma that is moist and reddish-pink, skin that is intact and free of irritation, and sutures that are intact. The stoma is edematous initially and shrinks over the next 4 to 6 weeks. A necrotic stoma is manifested by a purple or black color and a dry instead of moist texture. The stoma is functioning normally when the stoma drains a moderate amount of liquid or soft stool and flatus in the pouch. Flatus indicates the return of peristalsis after surgery. Flatus is noted by bulging of the pouch. (Flatus may not be observable if the pouch has a gas filter.)

DIF: Cognitive Level: Application REF: Text reference: p. 870

OBJ: Pouch a fecal or urinary diversion. TOP: Pouching a Colostomy or Ileostomy

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

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.

ANS: B

Because babies swallow large amounts of air while sucking, it is normal to expect flatus. Make sure that the pouch can accommodate increased amounts of flatus after feeding, or be prepared to release flatus frequently. The skin of a preterm infant is not fully developed and is more absorbent than the skin of a full-term infant. Do not use skin sealants and adhesive removers unless they are approved for preterm infant use. Neonates may have multiple stomas on their tiny abdomens that are the result of corrective bowel surgeries. Select a cut-to-fit pouch that allows multiple stoma openings in the skin barrier yet still fits on the neonates abdomen. Usually, a baby triples its birth weight in the first year. As a baby grows in size, so does the stoma.

DIF: Cognitive Level: Application REF: Text reference: p. 873

OBJ: Pouch a fecal or urinary diversion. TOP: Pediatric Considerations

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

8. 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.

ANS: A

Empty pouches when they are one-third to one-half full so that the weight of the pouch does not disrupt the seal. A surgeon places the stents; these will be removed during the hospital stay or at the first postoperative visit with the surgeon. Place the patient in a semi-reclining position. If possible, provide the patient a mirror for observation. Properly dispose of used pouches and soiled equipment according to facility policy.

DIF: Cognitive Level: Application REF: Text reference: p. 874

OBJ: Pouch a fecal or urinary diversion. TOP: Pouching a Urostomy

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

9. 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.

ANS: C

Mucous shreds are normal when urine flows through an intestinal segment. Obtain a urine specimen for culture and sensitivity to test for possible infection when ordered by the physician if urine output is less than 30 mL/hr, or if the urine has a foul odor. Teach patients the significance and importance of drinking 1.5 to 2 quarts of fluid daily to prevent urinary tract infection. Avoid soap; it leaves residue on the skin, which interferes with pouch adhesion.

DIF: Cognitive Level: Analysis REF: Text reference: p. 875

OBJ: Pouch a fecal or urinary diversion. TOP: Mucous Shreds

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

10. The nurse has removed the patients 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.

ANS: D

Wick the stoma continuously during pouch measurement and change. Place a rolled gauze wick at the stomal opening. Using a wick at the stoma opening prevents the peristomal skin from becoming wet with urine during a pouching-change procedure. Position the patient in a semi-reclining position. Avoid soap when cleansing the area. In the immediate postoperative period, urinary stents extend out from the stoma. A surgeon places the stents to prevent stenosis of the ureters at the site where the ureters are attached to the conduit. The stents will be removed during the hospital stay or at the first postoperative visit with the surgeon.

DIF: Cognitive Level: Application REF: Text reference: p. 878

OBJ: Pouch a fecal or urinary diversion. TOP: Wicking the Stoma

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

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.

ANS: D

The patient may shower without covering the pouch. Teach patients the significance and importance of drinking 1.5 to 2 quarts of fluid daily to prevent urinary tract infection. Patients should avoid storing pouches in extremely hot or cold locations like the refrigerator. Teach patients that some mucus in the urine is expected, but that they should report to their physician any blood in the urine, excessively cloudy urine, chills, fever (101 F or higher), or back (flank) pain.

DIF: Cognitive Level: Application REF: Text reference: p. 876

OBJ: Describe methods used to maintain the integrity of the peristomal skin.

TOP: Patient Education KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

12. 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 patients pouch.

b.

Catheterize the patient to obtain a sterile urine specimen.

c.

Notify the physician.

d.

Realize that these are normal findings.

ANS: C

Common symptoms of a UTI include fever and foul-smelling odor. The Nurse will need to contact the physician immediately. The physician will order a catheterization so that a urine sample may be obtained. Although the nurse realizes the need for catheterization, it is an invasive procedure, and an invasive procedure requires a physicians order. Obtaining a specimen of urine in a pouch does not result in an accurate finding because of the likely risk of contamination by microorganisms. Some mucus in the urine is expected.

DIF: Cognitive Level: Analysis REF: Text reference: p. 878

OBJ: Catheterize a urinary diversion. TOP: Urinary Infection

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

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.

ANS: C

Remove the pouch. If the patient uses a two-piece system, remove the pouch but leave the barrier attached to the skin. Position the patient sitting, if possible; gravity facilitates the flow of urine. Sterile gloves are used for the actual catheterization. Clean gloves are all that are necessary for removing the pouch.

DIF: Cognitive Level: Application REF: Text reference: p. 877

OBJ: Catheterize a urinary diversion. TOP: Removing the Pouch

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

MULTIPLE RESPONSE

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

ANS: A, B, C, D

In addition to the stresses of illness and surgical recovery, patients with ostomies face body image changes, fear of social rejection, concern about sexual function and intimacy, and the need for help with personal care. It is very important to provide an effective pouching system to facilitate the emotional adjustment to the ostomy. A supportive nurse makes the initial period of adjustment easier.

DIF: Cognitive Level: Analysis REF: Text reference: p. 868

OBJ: Identify types of fecal and urinary diversions.

TOP: Physical and Emotional Stressors Related to Ostomy Placement

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

COMPLETION

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

ANS:

stoma

Certain diseases or conditions require surgical intervention to create an opening into the abdominal wall for fecal or urinary elimination. This opening is called a stoma and is constructed from a section of colon or small intestine.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 866

OBJ: Identify types of fecal and urinary diversions. TOP: Stoma

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

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

ANS:

effluent

The output from the stoma is called the effluent.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 866

OBJ: Identify types of fecal and urinary diversions. TOP: Effluent

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

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

ANS:

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.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 866

OBJ: Identify types of fecal and urinary diversions. TOP: Colostomy

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

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

ANS:

ileostomy

An opening in the ileal portion of the small intestine is an ileostomy, and the fecal effluent will be watery to thick liquid that will contain some digestive enzymes.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 866

OBJ: Identify types of fecal and urinary diversions. TOP: Ileostomy

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

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) _____________.

ANS:

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.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 866

OBJ: Identify types of fecal and urinary diversions. TOP: Urostomy or Ileal Conduit

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

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