Ostomy Nclex Questions and Answers

Ostomy Nclex Questions and Answers Rated A

A client suffering with ulcerative colitis has discussed the need for a temporary colostomy to rest the colon and help the healing process. The colostomy will be located in the descending colon.

The type of stool that the client can expect from this stoma is:

• Liquid that cannot be regulated
• Malodorous and mushy drainage
• Increasingly solid
• Liquid fecal drainage
• Increasingly solid

Rationale: Stool in the descending colon is often formed, and the tissue can be trained for periodic defecation. Liquid stool and malodorous stool that cannot be controlled is found within the ascending colon. Malodorous, mushy stool is noted in the transverse colon. Output is always expected at some point in time from ostomies as evidence of their functioning.After having a transverse colostomy constructed for colon cancer, discharge planning for home care would include teaching about the ostomy appliance. Information appropriate for this

intervention would include:

• Instructing the client to report redness, swelling, fever, or pain at the site to the physician for

evaluation of infection

• Nothing can be done about the concerns of odor with the appliance.

• Ordering appliances through the client's health care provider
• The appliance will not be needed when traveling.
• Instructing the client to report redness, swelling, fever, or pain at the site to the physician

for evaluation of infection Rationale: Signs and symptoms for monitoring infection at the ostomy site are a priority evaluation for clients with new ostomies. The remaining actions are not appropriate. There are supplies avaliable for clients to help control odor that may be incurred because of the ostomy.Although a prescription for ostomy supplies is needed, you can order the supplies from any medical supplier. Dependent on the location and trainability of the ostomy, appliances are almost always worn throughout the day and when traveling.The nurse is most likely to report which finding to the primary care provider for a client who has an established colostomy?

• The stoma extends 1/2 in. above the abdomen.
• The skin under the appliance looks red briefly after removing the appliance.
• The stoma color is a deep red-purple.
• An ascending colostomy delivers liquid feces.
• The stoma color is a deep red-purple

Rationale: An established stoma should be dark pink like the color of the buccal mucosa and is slightly raised above the abdomen. The skin under the appliance may remain pink/red for a while after the adhesive is pulled off. Feces from an ascending ostomy are very liquid, less so from a transverse ostomy, and more solid from a descending or sigmoid stoma.

A client with a new stoma who has not had a bowel movement since surgery last week reports feeling nauseous. What is the appropriate nursing action?

• Prepare to irrigate the colostomy.
• After assessing the stoma and surrounding skin, notify the surgeon.
• Assess bowel sounds and administer antiemetic.
• Administer a bulk-forming laxative, and encourage increased fluids and exercise.
• After assessing the stoma and surrounding skin, notify the surgeon.

Rationale: The client has assessment findings consistent with complications of surgery. Option 1: Irrigating the stoma is a dependent nursing action, and is also intervention without appropriate assessment. Option 3: Assessing the peristomal skin area is an independent action, but administering an antiemetic is an intervention without appropriate assessment. Antiemetics are generally ordered to treat immediate postoperative nausea, not several days postoperative.Option 4: Administering a bulk-forming laxative to a nauseated postoperative client is contraindicated.When pouching a patient's colostomy, which action reduces the patient's risk for injury?

• Measuring output when emptying the contents of the pouch
• Maintaining the patient's bowel elimination function
• Promoting the patient's autonomy with bowel elimination care
• Protecting the skin from irritation caused by fecal drainage
• Protecting the skin from irritation caused by fecal drainage.

Protecting the skin from irritation caused by fecal drainage ensures correct pouching and prevents injury associated with skin breakdown.When changing the pouching system, which routine step best minimizes irritation of the skin surrounding the stoma?

• Using adhesive remover
• Emptying the ostomy bag only when full
• Avoiding unnecessary changes of the pouching system
• Wearing clean gloves
• Avoiding unnecessary changes of the pouching system

Each pouching system change increases the risk of irritating the surrounding skin tissue.Which instruction might the nurse give to nursing assistive personnel (NAP) regarding the care of a patient with a newly established colostomy?

• "Be sure to pat-dry the skin surrounding the stoma before applying the new pouch."
• "Alert me immediately if you see any blood in the fecal matter in the pouch."
• "Using the stoma guide, cut the pouch opening about one-eighth of an inch bigger than the

stoma."

• "Remember to change your gloves after cleaning the stoma and the surrounding skin."
• "Alert me immediately if you see any blood in the fecal matter in the pouch."

NAP can observe and report anomalies regarding the stoma, the pouch, or its contents