Fundamentals Exam 3
Which stoma assessments are appropriate? Select all that apply a) color b) swelling c) stoma type d) stoma trauma
All of the above All of the answer options represent appropriate assessments. Color should be reddish pink to indicate adequate circulation. Swelling should progressively decrease. The stoma may be flush with the skin or protrude slightly, referred to as a "bud stoma." Any trauma to the stoma, such as cracks or dryness, should be assessed.
True or false? "When a new ostomy is present, the stoma should be measured with each pouch change."
True - Measuring the stoma during each appliance change will ensure that the skin barrier opening is the correct size.
The opening of the skin barrier of an ostomy pouch should be how much bigger than the stoma itself? a) 1/16 inch b) 1/2 inch c) 3/4 inch d) 2/3 inch
a) 1/16 inch There should only be 1/16 to 1/8 inch of skin visible around the stoma after the appliance is in place. This prevents skin breakdown from contact with feces while allowing for passage of effluent through the stoma.
Identify the correct order for removal of an ostomy pouch and preparation of a new ostomy appliance. a) Perform hand hygiene and auscultate bowel sounds, apply clean gloves and remove the old appliance, clean the peristomal site, observe and measure the stoma b) Observe and measure the stoma, perform hand hygiene and auscultate bowel sounds, apply clean gloves and remove the old appliance, clean the peristomal site c) Apply clean gloves and remove the old appliance, clean the peristomal site, perform hand hygiene and auscultate bowel sounds, observe and measure the stoma d) Clean the peristomal site, observe and measure the stoma, apply clean gloves and remove the old appliance, perform hand hygiene and auscultate bowel sounds
a) Perform hand hygiene and auscultate bowel sounds, apply clean gloves and remove the old appliance, clean the peristomal site, observe and measure the stoma Hand hygiene should be completed before patient contact. Auscultation of bowel sounds should be completed before any manipulation of the abdomen that could stimulate bowel sounds. After removing the old appliance and cleaning the peristomal site, the stoma should be assessed and measured to determine the size needed for the opening of the skin barrier.
Psychologic stress is often experienced by patients with new ostomies. For which nursing diagnoses is a patient with a new ostomy most at risk? Select all that apply. a) anxiety b) ineffective coping c) chronic pain d) fear
a) anxiety b) ineffective coping d) fear Anxiety and fear related to changes in lifestyle and body image are common. Coping is often ineffective. Chronic pain is not commonly associated with ostomy patients unless other physiologic factors are present.
A nurse is caring for a patient who has been experiencing periods of incontinence during the night. Which intervention(s) is indicated at this time? Select all that apply. a) avoid fluid intake 2 ours prior to bedtime b) restricting fluids 4 hours before bedtime c) allowing the patient to have desired fluids up until the time for sleep and awaken the patient periodically during the night d) anchoring a catheter during the night to reduce problems associated with incontinence
a) avoid fluid intake 2 ours prior to bedtime c) allowing the patient to have desired fluids up until the time for sleep and awaken the patient periodically during the night To minimize nocturia, avoid fluids in the 2 hours before bedtime. Assisting the patient in toileting during the night has been shown to reduce episodes of incontinence. Restricting fluids for more than 4 hours before retiring is too long. Using a catheter is an overly invasive way to manage periods of incontinence and carries a series of risk factors.
The procedure that creates a pouch made from the end of the small intestine that is then attached to the anus for feces collection is known as: a) an ileoanal pouch anastamosis b) complete colectomy c) a Kick continent ileostomy d) a Macedo-Malone antegrade continence enema
a) ileoanal pouch anastomosis The procedure described, an ileoanal pouch anastomosis, is sometimes performed for patients in need of a colectomy as treatment for ulcerative colitis or familial polyps.
When evaluating the urinary output of a patient, a nurse recognizes that there is cause for concern if output is: a) > 30 mL/hr b) < 30 mL/hr c) < 35 mL/hr d) < 40 mL/hr
b) < 30 mL/hr
Which type of ostomy will likely result in formed effluent? a) ileostomy b) descending colostomy c) transverse colostomy d) ascending colostomy
b) descending colostomy The descending colostomy will produce the most formed effluent since most of the water is absorbed from the feces at this point in the colon.
When planning a bladder training program, a nurse recognizes that a good goal for voiding is every 3 to 4 hours in quantities of: a) 100-150 mL b) 150-200 mL c) 240-500 mL d) 350-550 mL
c) 240-500 mL When initiating a plan of bladder training, it is advised that attempts to empty the bladder be made every 3 to 4 hours. A quantity of 240 to 500 mL is encouraged.
As long as the skin barrier of an ostomy pouch is intact, the ostomy pouch only requires changing every a) 1-2 days b) 2-3 days c) 5-7 days d) 7-14 days
c) 5-7 days Limiting pouch changes to every 5 to 7 days prevents skin irritation that can result from removing intact skin barriers too frequently
A nurse is preparing to catheterize a female patient. When the catheter is advanced, the tubing should be inserted for a) 3-4 cm b) 4-5 cm c) 5-7.5 cm d) 6-8 cm
c) 5-7.5 cm In an attempt to insert a catheter, the tubing should be advanced a total of 5 to 7.5 cm (2 to 3 inches) or until urine flows out of the catheter's end. Force should not be used to insert the catheter.
A nurse is preparing to secure a condom catheter for a male patient. Which practice should be observed when applying the condom onto the penis? a) The nurse should allow at least 3 inches between the end of the penis and the end of the catheter. b) The nurse should avoid leaving space between the tip of the penis and the end of the catheter. c) The nurse should allow for a 1- to 2-inch space between the tip of the penis and the end of the catheter. d) The nurse should allow for 2 to 3 inches between the tip of the penis and the end of the catheter.
c) The nurse should allow for a 1- to 2-inch space between the tip of the penis and the end of the catheter. When applying the condom catheter, the nurse will need to allow for drainage space. This may be accomplished by leaving a 1- to 2-inch space between the tip of the penis and the end of the catheter.
Someone who is having difficulty coping with a colostomy should be referred to a) a doctor specializing in ostomies b) an enterostomal nurse c) an ostomy support group d) a psychologist
c) an ostomy support group Such groups consist of individuals who are having or have had the same experience
Which stoma assessment findings are causes for concern? Select all that apply a) moist b) pinkish red c) blue d) dry
c) blue d) dry Stomas should appear moist and pinkish red, indicating adequate circulation to the stoma.
A nurse is caring for a patient who requires bladder training. With what frequency should the nurse schedule toileting for this patient during the day and evening hours? a) every hour b) every 90 minutes c) every 2 hours d) every 3-4 hours
c) every 2 hours When planning a toileting schedule for the patient who is undergoing bladder training, the nurse should promote toileting every 2 hours. The goal is to avoid overfilling the bladder and in so doing, decrease the chance of incontinence related to increased bladder pressure.
The best way to release flatus from a colostomy bag is to a) change the skin barrier and pouch b) pull the upper portion of the pouch from the rim of the skin barrier c) loosen the clip to open the end of the pouch d) change the pouch
c) loosen the clip to open the end of the pouch Loosening the clip to open the end of the pouch is a simple way to release flatus from the pouch. Changing the skin barrier and/or pouch is not necessary for releasing flatus. Pulling the upper portion of the pouch from the skin barrier may allow effluent to escape.
A colostomy in the transverse colon means the effluent will most likely be a) liquid b) soft c) semi-formed d) near normal
c) semi formed A colostomy of the transverse colon will produce semi-formed effluent. An ileostomy will produce liquid effluent. A colostomy of the ascending colon will produce liquid to soft effluent. A colostomy of the sigmoid colon will produce near normal effluent.
A nurse is caring for a patient who has been diagnosed with a urinary tract infection. In the absence of contradictory health concerns, the nurse should encourage the patient to drink __________ mL of fluid each day. a) 500 b) 750 c) 1000 d) 2000
d) 2000 The recommended daily intake for fluid is 2000-2500 mL per day
The nursing diagnosis Risk for impaired skin integrity is most likely to apply to a patient with: a) a descending colostomy. b) a transverse colostomy. c) an ascending colostomy. d) an ileostomy.
d) an ileostomy An ileostomy places a patient at the greatest risk for impaired skin integrity due to the production of copious liquid effluent.
A patient who is at risk for urinary tract infections is reviewing potential menu selections for the upcoming day. Which menu selection will aid in the prevention of urinary tract infections? a) milk b) leafy greens c) bananas d) prunes
d) prunes Prunes are associated with an increase in acidity of the urine. Milk, leafy green vegetables, and bananas are not associated with an increase in the acidity of urine.
Someone who is 28 years old, mobile, able to use his hands without difficulty, and wants to manipulate his colostomy appliance as little as possible will most likely prefer which type? a) one-piece pouch with skin barrier attached b) precut pouch and skin barrier c) one-piece system with a long pouch d) two piece system
d) two-piece system A two-piece system allows for the skin barrier to stay in place for several days so that the pouch is the only part of the system that may need to be changed.
A nurse is changing a patient's colostomy appliance. The nurse should clean the peristomal skin with: a) hydrogen peroxide b) mild soap c) sterile normal saline d) warm tap water
d) warm tap water Warm tap water will not irritate the peristomal skin. The area should be cleansed gently and patted dry. Hydrogen peroxide will likely irritate the skin. Soap should be avoided because it leaves a residue that prevents the skin barrier from adhering to the skin. Sterile normal saline is not necessary.
