Question 1

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?

Accepted Answer

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 
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 D

Question 2

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

Accepted Answer

urostomy or ileal conduit
A urostomy or ileal conduit is created from a 6- to 8-inch portion of the intestine that is resected from the ileum.One end of the conduit is sutured closed,and the ureters are implanted through the mucosa.The other end is brought out of the abdominal wall,and a stoma is formed for urine to exit the body.

Question 3

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

Accepted Answer

continent urinary diversions
There are two types of continent urinary diversions.One is a continent urinary reservoir created from a distal portion of the ileum and a proximal portion of the colon.The ureters are embedded in the reservoir.This reservoir is situated under the abdominal wall and has a narrow ileal segment brought out through the abdominal wall to form a small stoma.The ileocecal valve creates a one-way valve in the pouch through which a catheter is inserted to empty the urine from the pouch.Patients must be able and willing to catheterize the pouch 4 to 6 times a day for the rest of their lives.The other type of continent urinary diversion is an orthotopic neobladder that also uses an ileal pouch to replace the bladder.Anatomically,the pouch is in the same position where the bladder was before removal,allowing the patient to void normally.

Question 4

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

Accepted Answer

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 
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 5

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?

Accepted Answer

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

Question 6

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?

Accepted Answer

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

Question 7

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.)

Accepted Answer

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 
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

Question 8

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

Accepted Answer

stoma
Certain diseases or conditions req

Question 9

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

Accepted Answer

effluent
The output

Question 10

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

Accepted Answer

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 
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 11

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.)

Accepted Answer

A)  Body image changes 
B)  Fear of social rejection 
C)  Sexual function and intimacy issues 
D)  Loss of independence 
E)   None of above 
A)  Body image changes 
B)  Fear of social rejection 
C)  Sexual function and intimacy issues 
D)  Loss of independence 
E)   None of above

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?

Accepted Answer

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 
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

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

Accepted Answer

ileostomy
An opening in the il

Question 14

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

Accepted Answer

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 
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 15

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

Accepted Answer

colostomy
An opening in the la

Question 16

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

Accepted Answer

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 
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 17

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

Accepted Answer

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 
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 18

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

Accepted Answer

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 
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 19

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?

Accepted Answer

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 
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 20

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

Accepted Answer

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

Exam 35: Ostomy Care

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?

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

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

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

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?

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?

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.)

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

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

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

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.)

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?

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

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

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

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

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

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

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?

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

Using Evidence in Nursing Practice

Admitting, transfer, and Discharge

Communication

Reporting and Recording

Vital Signs

Health Assessment

Medical Asepsis

Sterile Technique

Safe Patient Handling, transfer, and Positioning

Exercise and Ambulation

Orthopedic Measures

Support Surfaces and Special Beds

Safety

Disaster Preparedness

Pain Assessment and Basic Comfort Measures

Palliative Care

Personal Hygiene and Bedmaking

Pressure Ulcer Care

Care of Eye and Ear Prostheses

Safe Medication Preparation

Oral and Topical Medications

Parenteral Medications

Oxygen Therapy

Performing Chest Physiotherapy

Airway Management

Closed Chest Drainage

Emergency Measures for Life Support

Intravenous and Vascular Access Therapy

Blood Transfusions

Oral Nutrition

Enteral Nutrition

Parenteral Nutrition

Urinary Elimination

Bowel Elimination

Preoperativepostoperative Care

Intraoperative Care

Wound Care and Irrigations

Dressings,bandages,and Binders

Warm and Cold Therapy

Home Care Safety

Home Care Teaching

Specimen Collection

Diagnostic Procedures

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