Deck 35: Ostomy Care

Question 1

The patient has an ostomy that is putting out watery effluent.What is the most likely location for the ostomy?

A) The descending colon
B) The sigmoid colon
C) The ileal portion of the small intestine
D) The transverse colon

Answer 1

The ileal portion of the small intestine

Question 2

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 should the nurse do next?

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

Answer 2

Notify the physician

Question 3

Which of the following patients will have no control over time or frequency of output and will need to wear a pouch? (Select all that apply.)

A) The patient with a colostomy
B) The patient with an ileostomy
C) The patient with an ileal conduit
D) The patient with a urostomy
E) None of above

Answer 3

The patient with a colostomy
The patient with an ileostomy
The patient with an ileal conduit
The patient with a urostomy

Question 4

When assessing the patient with a noncontinent urinary diversion,the nurse finds that the urine has mucous shreds.What should the nurse do first?

A) Culture any drainage
B) Instruct patient to consume less water
C) Note the characteristics of the urine in her notes
D) Cleanse the stoma with soap and water

Question 5

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 stoma opening

Question 6

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

Question 7

Immediately after a fecal surgical diversion,it is necessary to:

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

Question 8

An ostomy that is created from a portion of the ileum to form a stoma for urine to exit the body is called a _____________.

Question 9

The nurse is preparing to catheterize a patient who has a urostomy and uses a two-piece pouch system.Which of the following actions is appropriate?

A) Place the patient in a semi-recumbent position
B) Remove both pieces of the pouch system
C) Remove the pouch only and leave the barrier attached
D) Use sterile gloves to remove the system

Question 10

Which of the following is an expected assessment finding for a colostomy or ileostomy?

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

Question 11

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

Question 12

The patient will be going home in a few days with a new urostomy.What should the nurse teach the patient about home care of his urostomy?

A) To restrict fluid intake to reduce urine output
B) To report any mucus in his urine
C) To keep unused pouches in the refrigerator
D) To shower without covering the pouch

Question 13

The nurse is caring for a patient who will have surgery in the morning to have a colostomy placed.The nurse needs to be aware of the physical and emotional stresses the patient will experience,including 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) None of above

Question 14

The nurse is caring for a preterm infant in the neonatal intensive care unit who has multiple stomas.How should the nurse proceed?

A) Apply an ostomy pouch using standard sealants
B) Use a pouch that can accommodate increased amounts of flatus
C) Use multiple pouches (once for each stoma)
D) Be aware that stoma size will remain the same as the baby grows

Question 15

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

Question 16

The nurse is caring for a patient who has an ostomy.She notices that the effluent is a thick liquid to a semiformed stool.Where does the nurse expect the ostomy to be located?

A) The descending colon
B) The ileal portion of the small intestine
C) The sigmoid colon
D) The transverse or ascending colon

Question 17

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.What should the nurse do?

A) Notify the physician immediately
B) Apply pressure
C) Note the condition of the stoma in her note
D) Change the appliance pouch

Question 18

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

Question 19

Which of the following actions is appropriate procedure for the nurse to use when pouching a noncontinent urinary diversion?

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

Question 20

What is an appropriate procedure for the nurse to implement when pouching a colostomy or ileostomy?

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

Question 21

The continent urinary reservoir and the orthotopic neobladder are examples of _____________.

Question 22

A temporary device placed by the surgeon during the creation of a urostomy and designed to prevent stenosis of the ureters at the site where the ureters are attached to the conduit is called a ______________.

Question 23

____________ of a urinary diversion is the only way to obtain an accurate culture and sensitivity specimen for screening for infection.