Chapter 20: Ostomy Care

Chapter 20: Ostomy Care

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE

 

1. 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.

 

 

ANS:  A

The nurse instructs the patient to expect a healthy stoma to be pinkish red, indicating adequate oxygenated blood flow, and slightly puffy because it is new. Since the stoma is highly vascular, there may be a little blood. A pale pink stoma indicates decreased blood flow. The stoma should be raised. New stomas drain and are pouched immediately after being created.

 

DIF:    Cognitive Level: Apply                   REF:   Page 535

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Implementation

 

2. 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.

 

 

ANS:  C

Patients usually need time to adjust to an abrupt body image change and a change in bodily function. Looking at the stoma and touching it would indicate the beginning of adapting to the changes. The patient needs to be able to be independent eventually in caring for his ostomy, but it is not expected that he would be caring for the stoma within a few days. The patient needs to talk about what type of clothing will work with the stoma well before discharge, but adjusting to the change in his body must come first.

 

DIF:    Cognitive Level: Apply                   REF:   Page 533| Page 535| Page 538

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Planning

 

3. 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.

 

 

ANS:  A

The nurse instructs a patient to measure the stoma with the measurement template so the stoma will have enough room to fit and to ensure that there is no excessive pressure on the stoma to impair its blood flow. The nurse instructs the patient to avoid covering the incisional area because it is unnecessary and can interfere with healing if the barrier covers a new surgical incision. Toilet tissue wicks can leave residue on the stoma. If a wick is made to absorb drainage, it should be made using gauze. The nurse avoids extending the skin barrier over the stoma to maintain adequate blood flow to the tissue.

 

DIF:    Cognitive Level: Remember            REF:   Page 536

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Implementation

 

4. 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.

 

 

ANS:  B

The nurse instructs the patient to change the pouch every 3 to 7 days unless it begins to leak, in which case the patient should change it earlier. The nurse encourages the patient to use the pouch as long as possible, within reason, because ostomy supplies are costly. The pouch is emptied when it is one-half to two-thirds full to prevent it from pulling away from the body. It can be emptied before going to bed and when the patient awakens. The nurse encourages the patient to empty the pouch before it is two-thirds full because a pouch filled to this level is very heavy and more likely to leak.

 

DIF:    Cognitive Level: Apply                   REF:   Page 535

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Implementation

 

5. 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

 

 

ANS:  C

Stool from an ileostomy can range from thin to thick liquid. Since no food is present, the effluent would be watery. Formed and semi-formed stool is more consistent with colostomy stool. The normal ileostomy stool when food is present is the consistency of a thickened liquid because there is a lot of water in the effluent since most water absorption occurs in the large intestine.

 

DIF:    Cognitive Level: Analyze                REF:   Page 532

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Assessment