Chapter 35 Ostomy Care

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Chapter 35  Ostomy Care

 

 

Complete Chapter Questions And Answers
 

Sample Questions

 

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

 

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