Ostomy Nclex Questions and Answers Rated A

Ostomy Nclex Questions and Answers Rated A

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• 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

4. Liquid fecal drainage: 3. 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, dis-

charge 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.: 1. 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.

Ostomy Nclex Questions and Answers Rated A

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• The skin under the appliance looks red briefly after removing the appli-

ance.

• The stoma color is a deep red-purple.

4. An ascending colostomy delivers liquid feces.: 3. 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.: 2. 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 peri-

stomal 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

4. Protecting the skin from irritation caused by fecal drainage: 4. Protecting

the skin from irritation caused by fecal drainage.

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Protecting the skin from irritation caused by fecal drainage ensures correct pouch- ing 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

4. Wearing clean gloves: 3. 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.": 2. "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

• A client who is scheduled for an ileostomy has an order for oral neomycin

(Mycifradin) to be administered before surgery. The intended outcome of

administering oral neomycin before surgery is to:

• Prevent postoperative bladder infection.
• Reduce the number of intestinal bacteria.
• Decrease the potential for postoperative hypostatic pneumonia.

4. Increase the body's immunologic response to the stressors of surgery.: 2.

Reduce the number of intestinal bacteria.

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The rationale for the administration of oral neomycin is to decrease intestinal bacteria and thereby decrease the potential for peritonitis and wound infection postoperatively. Neomycin will not alter the client's potential for developing a urinary or respiratory infection. Neomycin does not affect the body's immune system.

• A client has returned to the medical surgical unit after having surgery to

create an ileostomy. Which goal has the highest priority at this time?

• Providing relief from constipation.
• Assisting the client with self-care activities.
• Maintaining fluid and electrolyte balance.

4. Minimizing odor formation.: 3. Maintaining fluid and electrolyte balance.

A high-priority outcome after ileostomy surgery is the maintenance of fluid and electrolyte balance. The client will experience continuous liquid to semiliquid stools.The client should be engaged in self-care activities, and minimizing odor formation is important; however, these goals do not take priority over maintaining fluid and electrolyte balance.

• The nurse finds the client who has had an ileostomy crying. The client

explains to the nurse, "I'm upset because I know I won't be able to have children now that I have an ileostomy." Which of the following would be the best response for the nurse?

• "Many women with ileostomies decide to adopt. Why don't you consider

that option?"

• "Having an ileostomy does not necessarily mean that you can't bear

children. Let's talk about your concerns."

• "I can understand your reasons for being upset. Having children must be

important to you."

• "I'm sure you will adjust to this situation with time. Try not to be too

upset.": 2. "Having an ileostomy does not necessarily mean that you can't bear children. Let's talk about your concerns."

The fact that the client has an ileostomy does not necessarily mean that she cannot get pregnant and bear children. It may be recommended, however, that the number of pregnancies be limited. Women of childbearing age should be encouraged to discuss their concerns with their physician. Discussing their concerns about sexual functioning and pregnancy will help decrease fears and anxiety. Empathizing or telling the woman that she can adopt does not address her concerns. Her current