MED SURG 2 CH. 26 EAQ

The most important nursing action regarding postoperative care of the patient with a continent ileostomy is to assess for which factor? 1. Continuous drainage 2. Change in the color of drainage 3. Gradual increase in pouch capacity 4. Gradual increase in thickness of drainage

1. Continuous drainage Assessing for continuous drainage is most important because obstruction of the catheter can occur. After assessing for continuous drainage, the nurse would assess for change in the color of drainage and gradual increase in pouch capacity or thickness of drainage.

The nurse is caring for a patient who returned from ileostomy surgery 8 hours ago. The patient's stoma is red, bleeding lightly, and swollen. Which should be the nurse's priority action? 1. Document the findings. 2. Call the health care provider. 3. Prepare the patient to return to surgery. 4. Reposition the patient to relieve stress on the stoma

1. Document the findings. Immediately after surgery, the stoma should be beefy red, swollen, and will be lightly bleeding. These are normal findings, so the nurse should document the findings. It is not necessary to call the health care provider, prepare the patient to return to surgery, or reposition the patient to relieve stress on the stoma.

Which are factors to consider when deciding upon stoma placement? Select all that apply. 1. Ease of self-care 2. Placed below waist 3. Placed above waist 4. Located over bony prominence 5. Placed as close to umbilicus as possible 6. Placed over skin folds for better adherence.

1. Ease of self-care 2. Placed below waist Ease of self-care includes being able to see and touch the stoma. The stoma is placed below the waist if possible, in the margins of the rectus muscle to prevent peristomal hernias and allow better visibility. Placement above the waist would make visualization more difficult. Locating the stoma over a bony prominence, placing it close to the umbilicus, or placing it over skin folds would make achieving a good seal difficult, exposing the skin to drainage.

A wound, ostomy, and continence (WOC) nurse is teaching student nurses about self-health management of a new intestinal stoma. The nurse explains that students should observe for which first step in patient acceptance of the stoma? 1. Looking at it 2. Actively participating in stoma care 3. Verbalizing an interest in learning about self care 4. Allowing family members to participate in the care

1. Looking at it Some patients adjust more easily than others to an ostomy. A first step in accepting the stoma is looking at it. Patients should be encouraged but not forced to participate in the care. If a patient does not begin to show some interest in learning self-care techniques after a few days, then consider supportive resources.

The nurse is caring for a patient with a cutaneous ureterostomy. Which postoperative assessment finding should be of most concern? 1. Mucus in urine 2. Some blood in urine 3. Temperature of 99.2º Fahrenheit 4. Stoma smaller than an intestinal stoma

1. Mucus in urine Ureterostomy drainage should not contain mucus. A temperature of 99.2º warrants further monitoring but is not of concern. Some blood in urine is normal and should gradually clear. The stoma of a ureterostomy is usually smaller than that of an intestinal stoma.

Which information would the nurse include when teaching about irrigating a colostomy? Select all that apply. 1. The solution should flow slowly. 2. Irrigate early in the morning. 3. Irrigation takes 45 minutes to 1 hour. 4. Use 500- to 1000-mL lukewarm solution. 5. Apply pressure to the catheter if difficult to insert. 6. Cone-tipped catheters can be inserted 2 to 4 inches.

1. The solution should flow slowly. 3. Irrigation takes 45 minutes to 1 hour. 4. Use 500- to 1000-mL lukewarm solution. Solution should flow slowly into stoma, and, if cramping, slow or stop for a short time. The process of irrigation takes approximately 45 minutes to 1 hour. 500 mL of lukewarm irrigation solution is used but may be increased up to 1000 mL. The patient should select the time that is most convenient but should do it at the same time each day. Applying pressure to force the catheter increases the risk for perforation. Cone-tipped catheters are inserted approximately 1 inch. Other irrigating catheters may be inserted gently 2 to 4 inches.

A patient has concerns about sexual activity with an ostomy. Which information should the nurse include in the discussion with the patient? Select all that apply. 1. Use a pouch cover to conceal the pouch and its contents. 2. Empty and tape down the pouch before sexual intercourse. 3. Experiment with positions during intercourse that are most comfortable. 4. The patient will not likely be interested in sexual intercourse after surgery. 5. Recognize that the surgery is likely to interfere with the ability to conceive a child.

1. Use a pouch cover to conceal the pouch and its contents. 2. Empty and tape down the pouch before sexual intercourse. 3. Experiment with positions during intercourse that are most comfortable. The nurse should educate the patient to empty and tape down the pouch before sexual intercourse. This is important because it helps to minimize the pouch and make it easier to participate in sexual intercourse for both partners. After this, the nurse should tell the patient to use a pouch cover to conceal the pouch and its contents, and experiment with positions that are most comfortable. It is inappropriate and untrue that the patient will not be interested in sexual intercourse after surgery. The patient should be educated that surgery will not interfere with the ability to conceive a child.

A patient is having a cutaneous ureterostomy. Which information is factual regarding the procedure? Select all that apply. 1. The reservoir will hold the urine. 2. A pouch is needed to collect urine. 3. There is a risk for urinary tract infection. 4. If stenosis occurs, it will interfere with urine flow. 5. Hydronephrosis is a risk if there is an obstruction. 6. The stoma will be bright red immediately after surgery.

2. A pouch is needed to collect urine. 3. There is a risk for urinary tract infection. 4. If stenosis occurs, it will interfere with urine flow. 5. Hydronephrosis is a risk if there is an obstruction. A pouch is needed to collect urine from a cutaneous ureterostomy because urine drains from the stoma continuously. There is a risk for urinary tract infection, and this may damage the kidneys. Hydronephrosis occurs when the kidneys swell with urine due to obstruction. Stenosis interferes with urine flow by narrowing the stoma opening. There is no reservoir. Immediately after surgery, the stoma is pink.

The nurse is caring for a patient who has had surgery to create an ileoanal reservoir. The nurse should observe for which signs and/or symptoms of small bowel obstruction? Select all that apply. 1. Excoriated skin 2. Abdominal distention 3. Nausea and vomiting 4. Increased bowel sounds 5. Changes in bowel patterns

2. Abdominal distention 3. Nausea and vomiting 5. Changes in bowel patterns Bowel sounds decrease with a small bowel obstruction because intestinal motility decreases. Abdominal distention, nausea, vomiting, and changes in bowel patterns are also symptoms of small bowel obstruction. Skin excoriation is a complication resulting from stool leaking onto the skin.

A patient has a colostomy that was performed for a right-sided tumor in the intestine. The effluent is a liquid consistency. Which type of colostomy did the patient receive? 1. Sigmoid colostomy 2. Ascending colostomy 3. Transverse colostomy 4. Descending colostomy

2. Ascending colostomy An ascending colostomy is performed for right-sided tumors. The effluent is liquid in consistency. A sigmoid colostomy is done for tumors of the rectum, and the fecal matter is formed due to fluid being removed during passage through the intestines. A transverse colostomy is often done for obstruction or perforation, and the consistency ranges from liquid to semi-solid. Descending colostomies are performed for left-sided tumors. Feces become more formed depending on location as it nears the sigmoid colon.

A patient who had a colostomy 5 days ago is refusing to look at the stoma or participate in care. In talking with the patient, the nurse determines that he appears to be grieving and has many concerns regarding mortality, body image, and sexuality. In which stage of the process does this patient appear to be? 1. Anger 2. Denial 3. Bargaining 4. Depression 5. Acceptance

2. Denial Refusing to look at the stoma or participate in caring for the colostomy are symptoms of denial. These actions suggest denial by refusing to acknowledge the situation. There is no suggestion that any actions demonstrating anger are present. Bargaining would suggest trading the condition, such as, "If you make me whole again, I will be nicer." Depression may be present as well, but would likely make the patient unwilling to share feelings. Signs of acceptance would be indicated by the patient taking a more active role in care.

A patient has a double-barrel ostomy of the transverse colon. Which finding would the nurse expect to see? 1. Proximal stoma draining formed brown stool 2. Distal stoma draining scant amount of mucus 3. Distal stoma draining moderate amounts of formed stool 4. Copious amounts of brown liquid draining from both sections

2. Distal stoma draining scant amount of mucus The distal stoma is no longer attached to the bowel, and it is the mucus stoma. The proximal stoma would have stool that is liquid to soft, not formed. The distal stoma is no longer functional when a double-barrel ostomy is performed. Copious amounts of brown liquid would not drain from both sections as they are no longer connected.

The nurse is caring for a patient 36 hours after colostomy surgery. There has been no drainage from the colostomy. The patient denies abdominal pain, nausea, or vomiting. PO intake was started 12 hours ago. What should be the nurse's priority intervention? 1. Prohibit oral intake 2. Encourage ambulation 3. Call the health care provider 4. Prepare the patient for a return to surgery

2. Encourage ambulation Drainage from the colostomy usually starts on the third to fifth postoperative day after surgery. Ambulation stimulates peristalsis and will encourage drainage from the stoma. The nurse should encourage, not discourage, oral intake. Although the health care provider should be kept aware of the patient's status, it is not necessary to call the health care provider at this time. It is not appropriate to prepare the patient for surgery at this time.

Place the steps for applying a urinary pouch in order. 1. Place gauze over stoma. 2. Gather supplies, and remove pouch 3. Measure stoma, and cut opening in new appliance. 4. Prepare peristomal area with skin prep product. 5. Remove backing, and press gently with opening over stoma 6. Wash stoma and skin with water, and then pat dry.

2. Gather supplies, and remove pouch. 6. Wash stoma and skin with water, and then pat dry. 1. Place gauze over stoma. 3. Measure stoma, and cut opening in new appliance. 4. Prepare peristomal area with skin prep product. 5. Remove backing, and press gently with opening over stoma. Gather all supplies. Wash hands, don gloves, and then remove the pouch. Wash and dry the stoma and surrounding area with water, and pat dry to avoid irritation. Place a gauze pad over the stoma to collect drainage. Measure the stoma with the template, and cut an opening. Prepare the skin area with a preparatory product for better adherence and skin protection. Remove the backing from the adhesive on the new pouch, place the opening over the stoma, and press gently into place making sure that the appliance is pointing downward to facilitate drainage.

The nurse is collecting data on the appearance of the stoma of a patient with an ileostomy 2 days postoperatively. Which finding is of most concern? 1. Swelling 2. Pale pink color 3. Beefy red color 4. Small amount of bleeding

2. Pale pink color Pale pink color of the stoma is indicative of impaired circulation. A new stoma should be beefy red in color. Swelling of the stoma is expected and will shrink during the 6- to 8-week postoperative period. The small amount of bleeding may be considered reassuring rather than a source of concern, indicative of circulation to the stoma.

The new nurse employee is preparing to administer a tap water enema via a colostomy for a patient with constipation. Which action by the new nurse employee would cause the mentor to intervene? 1. Assisting the patient to the toilet and removing the pouch 2. Pouring 500 to 1000 mL of cool tap water into an enema bottle 3. Lubricating the tubing and inserting it 2 to 4 inches into the stoma 4. Applying an irrigating sleeve to the ostomy for drainage of feces into the toilet

2. Pouring 500 to 1000 mL of cool tap water into an enema bottle The mentor should intervene if the new employee is observed pouring 500 to 1000 mL of cool water into an enema bottle. Cool water can cause cramping and pain to the patient; lukewarm water should be used. The new nurse employee would be correct in assisting the patient to the toilet if able and removing the pouch. The nurse should then apply an irrigating sleeve, lubricate the tubing, and insert it 2 to 4 inches into the stoma.

Which is an example of a stoma in the urinary tract? 1. Ileostomy 2. Vesicostomy 3. Jejunostomy 4. Duodenostomy

2. Vesicostomy Examples of stomas in the urinary tract are the ureterostomy, ileal or colonic conduit, cystostomy, vesicostomy, and continent internal reservoir. An ileostomy, jejunostomy, and duodenostomy are created to drain fecal matter from the intestines.

When is the best time to have an ostomy patient participate in care of the ostomy? 1. The first day postoperatively 2. When the patient begins to watch 3. During an uninterrupted time for the nurse 4. During the first home visit, where the patient is in comfortable surroundings

2. When the patient begins to watch When the patient begins to watch the nurse performing care of the ostomy, it is an ideal time to encourage participation, so the patient can gradually take over self-care. The first day postoperative may be difficult due to pain, anxiety, and denial. The patient needs time to adjust to the change in body image. An uninterrupted time for the nurse may not coincide with the patient's receptive time. The home visit is too late for the patient to begin the learning process.

The nurse is providing preoperative teaching to a patient who is scheduled for surgical creation of a plain ileostomy. Which information is most important that the nurse relay to the patient? 1. A second stoma will be created to drain mucus. 2. A high-fiber diet will be important to prevent constipation. 3. A pouch will be necessary at all times due to frequent drainage of liquid stool. 4. A home health nurse will visit the patient to change the ostomy appliance every day.

3. A pouch will be necessary at all times due to frequent drainage of liquid stool. The nurse should educate the patient that he or she will need to wear a drainage pouch at all times because of the frequent drainage of liquid or pasty stools that the patient will be unable to control. A low-residue (or low-fiber) diet is necessary to prevent obstruction. For a plain ileostomy, a second stoma is not created; this would be a double-barrel ileostomy. Although a home health nurse may visit the patient to assist with ileostomy care in the beginning, the appliance is not changed every day unless it leaks.

Which are forms of urinary diversions? Select all that apply. 1. Ileostomy 2. Colostomy 3. Cystostomy 4. Ileal conduit 5. Jejunostomy 6. Ureterostomy

3. Cystostomy 4. Ileal conduit 6. Ureterostomy A cystostomy, ileal conduit, and ureterostomy are examples of urinary diversions that drain urine from the kidneys, ureters, or bladder. An ileostomy drains fecal matter from the small intestine. A colostomy drains fecal matter from the large intestine, and a jejunostomy drains fecal matter from the small intestine.

A patient is 12 hours post colostomy surgery. The patient has still not had drainage from the colostomy. What would be the nurse's priority action? 1. Call the health care provider. 2. Prepare the patient to return to surgery. 3. Explain to the patient this is a normal finding. 4. Instruct the patient to increase intake of unpeeled apples.

3. Explain to the patient this is a normal finding. Colostomy drainage begins the third to fifth postoperative day after surgery. The nurse should not be concerned for another 36 hours and should explain to the patient that this is a normal finding. It is inappropriate to call the health care provider or to prepare the patient to return to surgery at this time because it is normal for the patient to not yet have drainage from the colostomy. Patients should be instructed to not eat foods with a high residue, like fruits with peels, while the ostomy is still new.

The nurse is providing teaching to a patient with a new ileostomy. Which information should the nurse give the patient? 1. Eat a diet high in fiber to prevent obstruction. 2. Wear clothing snugly over the appliance to prevent leaking. 3. If the ostomy bulges from the skin, call the provider right away. 4. Call the provider if excessive gas is produced and collected in the bag.

3. If the ostomy bulges from the skin, call the provider right away. A drastic increase in the amount of tissue outside the skin may be a prolapse and should be seen by the provider. Additionally, a decrease in the size of the stoma over time (not a reduction in swelling) may indicate a stricture and should be seen by the provider. The patient should be instructed to eat a low-fiber diet to prevent obstruction. The patient can dress normally, but clothes should not be worn tightly over the stoma or bag. The patient should keep track of food that causes gas in order to avoid them in the future; the provider does not need to be notified.

Which type of ileostomy allows for nearly normal bowel evacuation? 1. Kock pouch 2. Bricker procedure 3. Ileal J pouch-anal anastomosis 4. Barnett continent internal reservoir

3. Ileal J pouch-anal anastomosis The Ileal J pouch-anal anastomosis forms a new rectum from the terminal ileum, allowing for nearly normal bowel evacuation. The Kock pouch creates a reservoir to hold liquid stool that is drained at intervals. The Bricker procedure is another name for an ileal conduit, a urinary diversion. The Barnett procedure is a modification of the Kock procedure.

What conditions would necessitate a permanent urinary diversion rather than a temporary diversion? Select all that apply. 1. Urinary calculi 2. Bypass for healing of ureters 3. Irremovable obstruction in the bladder 4. Malignant carcinoma of the bladder 5. Congenital malformation of the bladder 6. Damaged sphincters of the bladder and detrusor muscle

3. Irremovable obstruction in the bladder 4. Malignant carcinoma of the bladder 5. Congenital malformation of the bladder 6. Damaged sphincters of the bladder and detrusor muscle A permanent urinary diversion would be used when it is not possible to remove an obstruction in the bladder. Malignant carcinoma of the bladder and congenital malformations of the bladder would cause conditions in which a permanent diversion would be needed. A temporary urinary diversion may be used when there is obstruction to urine flow such as urinary calculi. The temporary diversion would allow for healing of the ureters or bladder.

A patient is being educated in the care of a plain ileostomy. The nurse knows that the patient understands the information if the patient identifies the ileostomy will be draining which type of stool? 1. Dark, formed stool 2. Thick, bloody stool 3. Liquid-to-pasty stool 4. Bulky and frothy stool

3. Liquid-to-pasty stool The plain ileostomy frequently or intermittently drains liquid-to-pasty stool; consequently, the patient will always have to wear a pouch. Dark, formed stool would drain from a colostomy. Thick, bloody stool is not a normal finding, and the health care provider should be notified if this occurs. Bulky and frothy stool occurs in patients with celiac disease.

The nurse is preparing for a patient to return from surgery for the creation of an ileostomy. What should the nurse have in the room to care for the patient? 1. Tracheostomy tray 2. Crackers and lemon-lime soda 3. Low intermittent suction 4. Urinary drainage bag

3. Low intermittent suction Following ileostomy surgery, the patient will have a nasogastric tube placed and it will need to be attached to low intermittent suction. Immediately after surgery, the patient will receive intravenous fluids; oral intake will be encouraged later. The patient is not likely to require a tracheostomy after abdominal surgery. The patient may not necessarily have an indwelling catheter, so a urinary drainage bag might not be necessary.

Which procedure drains urine from the kidney to a tube that exits from the skin? 1. Ileal conduit 2. Vesicostomy 3. Nephrostomy 4. Cutaneous ureterostomy

3. Nephrostomy A nephrostomy tube drains urine directly from the kidney through a tube that exits from the skin. A vesicostomy is an opening into the bladder. An Ileal conduit is a drainage system made from a portion of the small intestine. A cutaneous ureterostomy is when the ureters are brought out through an opening in either the abdomen or flank.

The nurse is receiving a morning report on a patient who recently underwent surgery to have a tube placed that diverts urine directly from the kidney through a tube that exits through the skin. The nurse knows that this patient has which type of urinary diversion? 1. Cystostomy tube 2. Vesicostomy tube 3. Nephrostomy tube 4. Cutaneous ureterostomy tube

3. Nephrostomy tube Urine is diverted directly from the kidney through a nephrostomy tube that exits through the skin. A cystostomy (vesicostomy) tube provides an opening into the urinary bladder. A cutaneous ureterostomy tube is created when one or both ureters are brought out through an opening in the abdomen or flank.

The licensed practical nurse (LPN) is assisting with the irrigation of the patient's colostomy. Which would be the nurse's priority action? 1. Ask the patient to sit on the toilet if possible. 2. Remove the old pouch, and apply an irrigating sleeve. 3. Pour irrigating solution into the enema fluid container. 4. Ask the patient to choose the time of day that is most convenient.

4. Ask the patient to choose the time of day that is most convenient. Colostomy irrigation should be done at the same time every day. Although it is important to ask the patient to sit on the toilet if possible, remove the old pouch and apply an irrigating sleeve, and pour the irrigating solution into the enema fluid container, the first intervention is to ask the patient to choose a convenient time of day so that the procedure can be performed at the same time every day.

The nurse is assessing a colostomy in a patient who had a partial colectomy 24 hours ago. Which of these assessment findings is considered normal for a new stoma? 1. Pale pink color 2. Dusky blue color 3. Brown or black color 4. Beefy red, darker than oral mucosa

4. Beefy red, darker than oral mucosa The stoma should be beefy red, darker than the oral mucosa. The stoma should not be pale and pink. A dusky blue stoma indicates ischemia, and a brown-black stoma indicates necrosis. Assess and document stoma color every four hours and ensure that there is no excessive bleeding.

The nurse is planning teaching for a patient who had surgery for creation of a ureterostomy 2 days ago. Which intervention is best to encourage self-care at this time? 1. Ask the patient to assist in cleansing the peristomal area. 2. Allow the patient to cleanse the peristomal area independently. 3. Quickly and efficiently cleanse the peristomal area so the patient can rest. 4. Cleanse the peristomal area while explaining each step and why it is done.

4. Cleanse the peristomal area while explaining each step and why it is done. Initially after ureterostomy surgery, the nurse would cleanse the peristomal area while explaining each step and why it is done to prepare the patient for caring for the ureterostomy independently. The patient may not be ready to participate in the care of the ostomy this soon after surgery. It would most likely be overwhelming to the patient 2 days after surgery to have the patient cleanse the peristomal area independently. Unless the patient is unconscious, it is not appropriate to cleanse the peristomal area without involving the patient.

The nurse explains to a patient who is scheduled for abdominal surgery, "An internal pouch is created from a loop of ileum for storing fecal matter." Which procedure is the nurse explaining? 1. Ileostomy 2. Colostomy 3. Ileoanal reservoir 4. Continent ileostomy

4. Continent ileostomy A continent ileostomy is a surgical procedure that includes the creation of an internal pouch from a loop of ileum for the storage of fecal matter. An ileostomy is a surgical opening in the ileum. A colostomy is a surgical opening in the colon that allows direct elimination of fecal matter, but it does not involve any pouch or sac. An ileoanal reservoir is a complex set of surgical procedures similar to continent ileostomy except that the fecal matter is stored and then eliminated through the rectum.

Which signs and symptoms indicate that a patient with an ileoanal reservoir has developed peritonitis? 1. Bloody diarrhea 2. A change in bowel patterns 3. An decrease in temperature 4. Elevated white blood cell count

4. Elevated white blood cell count Peritonitis is a major complication associated with a temporary ileostomy, which includes an ileoanal reservoir. The characteristic features of peritonitis include an elevated white blood cell count. Bloody diarrhea is a manifestation of inflammation that occurs as a complication of an ileoanal reservoir. A change in bowel patterns and decreased bowel sounds are characteristic manifestations of a small bowel obstruction, which occurs as a complication of an ileoanal reservoir. An increase in temperature rather than a decrease is a sign of peritonitis.

The nurse is caring for a postoperative patient with an ileoanal reservoir. The nurse notices the presence of bloody diarrhea, and the patient reports no appetite and pain. These symptoms are indicative of which potential major complication? 1. Strictures 2. Peritonitis 3. Obstruction 4. Inflammation

4. Inflammation Bloody diarrhea, anorexia, and pain are signs and symptoms of inflammation of the reservoir. Scar tissue or strictures may cause obstruction. Signs and symptoms of small bowel obstruction are abdominal distention, nausea and vomiting, decreased bowel sounds, and changes in bowel patterns. Signs and symptoms are increased pulse and respiration rates, an elevated temperature, rigid abdomen and abdominal pain, and an elevated white blood cell count.

A patient with a ureterosigmoidostomy is at risk for electrolyte imbalances due to the colon's absorption of electrolytes from the urine. Which deficit is the patient at risk for due to this phenomenon? 1. Sodium 2. Chloride 3. Hydrogen 4. Potassium

4. Potassium The patient with a ureterosigmoidostomy is at risk for deficits in potassium and bicarbonate. These patients are not at risk for excesses in sodium, chloride, and hydrogen.

The licensed practical nurse (LPN) is assisting with data collection for a patient with an ostomy. Which initial aspect is determined as part of the patient's health history? 1. Response to surgery 2. Level of consciousness 3. Anticipated effects on lifestyle 4. Type of ostomy procedure performed and reason it was needed

4. Type of ostomy procedure performed and reason it was needed It is most important to ask about the type of ostomy procedure performed and the reason it was needed because this is the chief complaint. Determining the patient's response to surgery is part of the functional assessment. Determining the patient's level of consciousness is part of the physical examination. Determining the anticipated effects on lifestyle is part of the functional assessment.

Which are normal findings in a patient with an ileal conduit? Select all that apply. 1. Mucus in the drainage 2. Permanent absence of bowel activity 3. A ureteral stent in place to drain urine 4. A pouch attached to a collection device at night 5. Oral fluids are encouraged within 24 hours postoperatively

1. Mucus in the drainage 2. Permanent absence of bowel activity 4. A pouch attached to a collection device at night Mucus is normally present in drainage from a conduit because it is produced by the lining of the bowel segment. All patients with ileal conduits are advised to attach the pouch to a collection device during the night. A ureteral catheter or stent may be in place to drain urine. A temporary, not permanent, ileus (absence of bowel activity) is expected after bowel resection. The patient is NPO until bowel sounds return.

Postoperative care of a patient with an ileostomy includes watching for fluid imbalance. When the patient is able to resume oral intake, which is the best recommendation? 1. Drink 120 mL of a variety of fluids. 2. Drink more than 2 L of water. 3. Drink at least 1 L of water in 24 hours. 4. Take in at least 68 oz of a variety of fluids.

4. Take in at least 68 oz of a variety of fluids. The best recommendation is to take in at least 68 ounces of a variety of fluids, which is within the recommended 2 to 3 liters per day. Drinking 120 mL of fluid is inadequate. Drinking more than 2 liters of water is an adequate quantity but does not provide electrolytes. One liter of water is not adequate and will not provide electrolytes. A variety of fluids is recommended to obtain electrolytes.

Which image shows a type of colostomy that is usually permanent? 1 2 3

answer: 1 The single barrel colostomy is usually permanent. The double barrel colostomy as depicted in image 2 is usually temporary. Image 3 is a loop colostomy, which is temporary and supported by a brace.

Which action would be most appropriate for a shiny red area around a urinary stoma? 1. Apply nystatin powder. 2. Cleanse the area with undiluted vinegar. 3. Apply lotrimin cream under the appliance. 4. Cut the opening ¼ inch larger than the stoma.

1. Apply nystatin powder. The most appropriate action is to obtain an order for and apply nystatin powder to a yeast infection, which commonly occurs in a warm, moist environment. Cleansing with undiluted vinegar would cause burning. A cut ¼ inch larger than the stoma is too large and would expose skin to urine. Application of lotrimin cream would prevent the pouch appliance from adhering.

The nurse enters the room of a patient who is 2 days postoperative after having a colostomy. The patient appears visibly upset and is tearful. Which reply would be most appropriate? 1. "You seem upset. What's going on?" 2. "Don't cry, you are fortunate the doctor cured your cancer." 3. "I will get pain medication right now, and you will feel better." 4. "Things are bleak now but will get better as you learn to care for the ostomy."

1. "You seem upset. What's going on?" Acknowledging that the patient is upset and asking an open-ended question will allow the patient to express concerns. Feelings may be due to alteration in body image, pain, or many other causes. Telling patients not to cry because they are cured is inappropriate and closes communication. In addition, there is no certainty that a condition is cured. Offering to get pain medication without ascertaining that pain is the problem is not helpful. The patient may be depressed or upset for reasons other than pain. The patient may not feel better while learning to care for the ostomy, and the statement does not encourage verbalization.

A continent internal reservoir is being created for urinary diversion. A neobladder will be made using a section of intestine attached to the urethra and ureters. The patient asks what part of the intestine is to be used for the procedure. Which is the nurse's best response? 1. A segment of the ileum 2. A segment of the jejunum 3. A segment of the ascending colon 4. A small section of the transverse colon

1. A segment of the ileum The neobladder uses a resected segment of the ileum that is attached to the urethra and ureters. Urine drains from the reservoir through the urethra instead of a stoma. The ileum rather than jejunum is used for the procedure. The large intestine is not used.

Which is considered an advantage of a Kock pouch over a plain ileostomy? 1. Can drain liquid stool at intervals 2. Decreased odor in the collection bag 3. No restrictions on diet such as cruciferous vegetables 4. Ideal for persons with Crohn's disease or ulcerative colitis

1. Can drain liquid stool at intervals The Kock pouch creates a reservoir for fecal matter that has the advantage of being drained at intervals rather than being unpredictable. There is no need to wear a collection bag when the Kock pouch is regulated. Cruciferous vegetables that may cause gas and seeded items that may cause obstruction should be avoided. Patients with ulcerative colitis are candidates for a continent ileostomy, but those with Crohn's disease are usually not eligible.

The nurse is caring for an 82-year-old patient with a cutaneous ureterostomy. The nurse would look for which signs and symptoms of complications of a ureterostomy? Select all that apply. 1. Chills 2. Diarrhea 3. Joint pain 4. Flank pain 5. Confusion 6. Heart palpitations

1. Chills 4. Flank pain 5. Confusion The patient with a cutaneous ureterostomy is at a significantly increased risk for urinary tract and kidney infections due to the direct path for bacteria that the ureterostomy provides. Signs of kidney infection in an older adult include chills, flank pain, and confusion. Diarrhea, joint pain, and heart palpitations are not signs of urinary tract infection in older adults.

Which type of colostomy is performed for rectal tumors? 1. Sigmoid 2. Ascending 3. Transverse 4. Descending

1. Sigmoid A sigmoid colostomy is performed for rectal tumors. An ascending colostomy is performed for right-sided tumors. A transverse colostomy is performed in medical emergencies or for intestinal obstruction. A descending colostomy is performed for left-sided tumors.

Which complication is most likely with narrowing at the opening of the base of the stoma of a colostomy patient? 1. Stenosis 2. Necrosis 3. Prolapse 4. Excoriation

1. Stenosis Stenosis is narrowing of the abdominal opening around the base of the stoma. If severe, it can block the passage of feces. Necrosis is caused by diminished blood supply. Prolapse occurs when the stoma protrudes farther than usual due to increased abdominal pressure. Excoriation is damage to the skin around the stoma caused by contact with feces.

Which are indications for a temporary rather than permanent ostomy? Select all that apply. 1. Trauma 2. Infection 3. Cancer of the colon 4. Severe inflammation 5. Cancer of the bladder 6. Severe inflammatory bowel disease

1. Trauma 2. Infection 4. Severe inflammation A temporary ostomy may be done for trauma, infection, or severe inflammation to bypass the bowel or bladder and allow time to heal. Cancer of the colon, cancer of the bladder, and severe inflammatory bowel disease are indications for a permanent ostomy.

The nurse is providing postoperative teaching for a patient with a single-barrel colostomy. Which statement made by the patient indicates an understanding of self-care of the colostomy? 1. "I will vigorously clean the stoma with soap and water." 2. "I will use a skin sealant and barrier powder to the area surrounding the stoma." 3. "I will remove the appliance every other day to cleanse the area around the stoma." 4. "I will measure and cut the appliance to create an opening ½ inch around the stoma."

2. "I will use a skin sealant and barrier powder to the area surrounding the stoma." Every 3 to 5 days, the patient should gently remove the appliance for cleansing of the skin around the stoma. The area around the stoma should be cleansed gently to prevent skin breakdown. A skin sealant and barrier powder (or some other barrier substance) should be applied to the skin around the stoma. The appliance should be cut to 1/16 to 1/8 inch around the stoma.

Which response would be most appropriate when a patient with an ostomy expresses concerns regarding sexuality? 1. "You're still the same person, so it should not matter." 2. "What is concerning you about your sexuality since having the ostomy?" 3. "Your significant other loves you and will accept the ostomy as a part of you." 4. "Ask your partner to hold off on sex until you are more comfortable with having the pouch."

2. "What is concerning you about your sexuality since having the ostomy?" Asking what the concerns are is most appropriate. Practical suggestions may help alleviate some of the concerns. Telling a person that it should not matter negates concerns and could put up blocks to effective communication. Unless the nurse has spoken with and knows the partner's feelings, this statement may not be correct. Delaying sex until the patient is comfortable does not address concerns.

Which location of an ostomy is expected to have the most liquid effluent? 1. Colostomy in sigmoid colon 2. Colostomy in ascending colon 3. Colostomy in transverse colon 4. Colostomy in descending colon

2. Colostomy in ascending colon A colostomy in the ascending colon would have the most liquid effluent, and become more formed as water is absorbed during movement through the transverse, then descending, and sigmoid colon.

The LPN is educating a patient with a continent ileostomy about dietary restrictions. The LPN knows that the patient understands instructions if the patient avoids which items? 1. Coffee and alcohol 2. Corn, olives, and peas 3. Milk, yogurt, and cheese 4. Fresh fruit, especially pineapple and berries

2. Corn, olives, and peas Foods with skins, seeds, and nuts should be avoided, especially corn, olives, and peas. Coffee, alcohol, and other gas-forming foods should be avoided initially but not indefinitely. Milk products should only be avoided if they cause excessive gas. Fresh fruit, particularly pineapple and berries, should be avoided initially but not indefinitely.

The student nurse is preparing a presentation on ileostomies. For which diseases might an ileostomy be necessary? Select all that apply. 1. Diabetes 2. Multiple polyposis 3. Gluten intolerance 4. Inflammatory bowel disease 5. Systemic lupus erythematosus

2. Multiple polyposis 4. Inflammatory bowel disease An ileostomy is necessary for any condition that requires the entire colon to be removed. These include multiple polyposis, inflammatory bowel disease, bowel trauma, and cancer. Diabetes, gluten intolerance, and systemic lupus erythematosus are not likely to lead to an ileostomy.

While changing an ostomy appliance, the stoma appears pale and bluish. Which is an appropriate action by the nurse? 1. Cleanse the area well, and continue to monitor status. 2. Notify the surgeon as intervention is needed to restore circulation. 3. Cut the appliance opening slightly larger on the replacement wafer. 4. Recognize that this is normal, and continue to replace the appliance.

2. Notify the surgeon as intervention is needed to restore circulation. A stoma that is pale or bluish is indicative of impaired blood flow, and unless circulation is restored, the stoma will become necrotic. Surgical intervention will be needed to restore blood flow.

How should the stoma appear for a patient who had a colostomy 3 months ago? 1. Black 2. Rose red 3. Pale blue 4. Beefy red

2. Rose red At 3 months, the stoma should be healed and a rose red color, somewhat darker than oral mucosa would be expected. A stoma that is black, blue, or pale in appearance would be indicative of impaired circulation. A beefy red appearance would be expected for a new stoma.

The nurse is providing patient education to a patient with a cutaneous ureterostomy regarding changing the collection pouch. Which statement made by the patient indicates an understanding of how best to care for the pouch? 1. "I will change the pouch every 2 to 3 days." 2. "I will vigorously scrub the adhesive from the skin surrounding the stoma." 3. "I will change the pouch in the morning when urinary production is at its lowest." 4. "I will not place anything over the opening after I've removed the pouch to allow air to reach the stoma."

3. "I will change the pouch in the morning when urinary production is at its lowest." The ureterostomy pouch should be changed in the morning, when urine production is at its lowest. This should be done every 4 to 6 days; more frequent changes or vigorous scrubbing could lead to skin breakdown. The patient should place gauze over the stoma to absorb urine while gently removing the adhesive from the peristomal skin.

The nurse is preparing a patient for surgical creation of a single-barrel colostomy. Which statement made by the patient indicates a need for further teaching? 1. "Only part of my colon will be present in my abdomen." 2. "Stool that I pass will exit through the stoma and into a collection bag." 3. "Thank goodness I won't have to deal with this stoma for the rest of my life." 4. "Although it will take work, I'm confident that I'll be able to care for my colostomy on my own."

3. "Thank goodness I won't have to deal with this stoma for the rest of my life." This ostomy is permanent, and the patient should be educated as such. A single-barrel colostomy is one in which the distal portion of the colon from where the stoma is made is removed or closed and allowed to remain in place. Stool produced by the patient passes through the stoma and into a collection bag. It is important for independent living for the patient to learn to care for the ostomy independently.

Which order should the nurse question preoperatively for a fecal diversion? 1. Laxatives 2. Cathartics 3. High-fiber diet 4. Antibiotics that pass through the intestinal tract

3. High-fiber diet Before a fecal diversion, a low-fiber diet may be prescribed to clear the intestinal tract. Laxatives and cathartics are ordered to clear the intestinal tract. Antibiotics that pass through the intestinal tract are given to lower the risk for bacteria contaminating the abdomen when the bowel is open during surgery

The nurse is teaching a patient how to care for a colostomy. Place the steps of performing ostomy care in order from first to last. 1. Remove adhesive. 2. Apply pouch 3. Remove appliance 4. Apply protective barrier. 5. Observe skin for areas of breakdown 6. Cleanse area around stoma with water. 7. Cut wafer to within 1/8 inch size of stoma 8. Place wafer over stoma, and press down.

3. Remove appliance 1. Remove adhesive. 6. Cleanse area around stoma with water. 5. Observe skin for areas of breakdown 4. Apply protective barrier. 7. Cut wafer to within 1/8 inch size of stoma 8. Place wafer over stoma, and press down. 2. Apply pouch The appliance should be removed every 3 to 5 days or more frequently if leakage is present. Adhesive on the skin must be removed and may require a commercial adhesive remover. Cleanse the stoma and surrounding area with water, and pat dry. Observe the skin for redness or breakdown. Apply a protective barrier/skin sealant, which may be a wipe or other form. If the wafer is not precut, cut an opening 1/8 to 1/16 inch of stoma size. Peel off backing, and place over stoma while pressing down and avoiding creases. Apply pouch.

Which information should be included in a teaching plan for a patient with a ureterostomy? Select all that apply. 1. Clean the pouch weekly. 2. Pouch care is a sterile procedure. 3. Wash the peristomal area with water. 4. Ureterostomy drainage usually contains mucous. 5. Use karaya to protect the skin around the stoma. 6. Dilute vinegar can be used to dissolve crystals, if present.

3. Wash the peristomal area with water. 6. Dilute vinegar can be used to dissolve crystals, if present. The peristomal area should be cleansed with water and patted dry. If crystals are present, gauze saturated with dilute vinegar may be used to dissolve them. The pouch is usually cleansed once or twice daily. Pouch care is a clean rather than sterile procedure. The ureterostomy drainage should not contain mucous. Karaya is not used, as urine degrades the product

A patient has a newly formed ileostomy and asks the nurse, "When can I start training my ostomy to only produce stool at certain times?" What is the nurse's appropriate response? 1. "We will start training when the stoma heals." 2. "When your stools transition from liquid to semisolid." 3. "Because you have an ileostomy and not a colostomy, we can start any time." 4. "We will not be able to train your ileostomy because of the frequent drainage from the site."

4. "We will not be able to train your ileostomy because of the frequent drainage from the site." Drainage from the ileostomy is frequent, of liquid consistency, and irritating to the skin, preventing regularity from being established. Not all colostomies can be trained. A colostomy formed in the sigmoid or descending colon produces semiformed or formed stools and can be regulated by the irrigation method.

Which population in the United States has the highest rates of colon and rectal cancers? 1. Hispanics 2. Caucasians 3. Native American 4. African Americans

4. African Americans African Americans have the highest rates of colon and rectal cancers necessitating counseling regarding importance of screening, early detection, and treatment. While all persons are at risk, being Hispanic, Caucasian, or Native American does not place a person at as much risk.

The nurse is assessing the intestinal stoma of a patient 1 day after surgery. The nurse expects a new intestinal stoma to appear which color? 1. Pale 2. Bluish 3. Rose red 4. Beefy red

4. Beefy red A new intestinal stoma should be beefy red. When healed, an intestinal stoma should be rose red, somewhat darker than the color of the oral mucosa. A very pale, bluish, or black stoma has impaired circulation and must be immediately reported to the registered nurse or the health care provider.