26: Chapter The Patient with an Ostomy
MULTIPLE CHOICE 1. The nurse explains that an artificial opening into a body cavity is a(n): 1. gastrostomy. 2. ostomy. 3. colonoscopy. 4. ureterostomy. ANS: 2 An ostomy is an artificial opening into a body cavity. PTS: 1 DIF: Cognitive Level: Knowledge OBJ: 3 TOP: Terminology KEY: Nursing Process Step: Implementation REF: 396 MSC: NCLEX: N/A
2. The colostomy patient is instructed to measure the width of the stomas for the first 6 weeks postoperatively before applying each new pouch because: 1. the stoma will shrink during this time. 2. a poor-fitting pouch will cause infection of the stoma. 3. the paste will not adhere. 4. prolapse will result. ANS: 1 During the first 6 weeks, the stoma normally shrinks. The pouch needs to fit as closely to the stoma as is comfortable and safe to prevent skin irritation. PTS: 1 DIF: Cognitive Level: Application REF: 406 OBJ: 4 TOP: Pouch Fit KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. A 47-year-old patient who is 3 days postsurgery with a permanent colostomy reports some abdominal discomfort and abdominal rigidity. The assessment that the nurse should report and record is: 1. vital signstemperature, 100; pulse, 92; blood pressure, 160/98. 2. stoma is swollen and red; small amount of blood at base. 3. pouch drainage of 110 mL green-brown liquid, oozing from pouch edges. 4. stoma is protruding. ANS: 1 Vital signs in conjunction with complaint of abdominal discomfort should be reported and recorded as possible signs of impending peritonitis. PTS: OBJ: KEY: MSC: 1 DIF: Cognitive Level: Application REF: 403 4 TOP: Signs of Peritonitis in a Postoperative Colostomy Patient Nursing Process Step: Implementation NCLEX: Physiological Integrity
4. The nurse is aware that many ostomates have an altered self-image, which may cause: 1. self-care deficits. 2. sexual dysfunction. 3. nonadherence to diet. 4. irrational anger. ANS: 2 A damaged self-image or body image may cause ostomates to feel unattractive and embarrassed about possible sexual activity. Open-ended questions assist the patient to talk about their feelings. PTS: 1 DIF: Cognitive Level: Application REF: 400 and 410 OBJ: 4, 7 TOP: Self-Concept Issues in an Ostomate KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity 5. To ensure a good fit of the appliance to avoid leakage, which of the following should the nurse consider for pouch placement? 1. Place the pouch only when the patient is lying down. 2. The pouch placement should be checked for sitting comfort, standing comfort, and ambulation. 3. The pouch should fit very snugly to edges of stoma. 4. The pouch must cover the entire abdomen. ANS: 2 Placement of the pouch should be comfortable in all positions, but not too snug on the stoma for fear of laceration. The pouch need only cover enough of the abdomen to allow for a firm fit. PTS: OBJ: KEY: MSC: 1 DIF: Cognitive Level: Application 4 TOP: Placement of the Stoma Nursing Process Step: Implementation NCLEX: Health Promotion and Maintenance REF: 399
6. In assisting a colostomy patient choose an appropriate diet with little risk of excess gas or diarrhea, the nurse would encourage the patient to choose: 1. roast beef, mashed potatoes, peeled stewed tomatoes. 2. broiled pork chop, boiled potato, corn on the cob. 3. broiled trout, mashed potatoes, spinach. 4. BBQ on white bun, coleslaw, French fries. ANS: 1 Gas-forming or spicy foods and roughage, such as corn, fish, and cabbage, usually cause gas and diarrhea. PTS: 1 DIF: Cognitive Level: Analysis REF: 403-404 OBJ: 7 TOP: Ostomy Nutrition Teaching KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
7. A patient who has had a temporary colostomy to rest his ulcerated bowel says, I dont know how I will continue to work at my job with this thing stuck to my stomach. The nurses best response to stimulate communication would be: 1. This is only a temporary adjustment for you and the colostomy will be reanastomosed in less than 6 months. 2. A nurse with special training will be in to help you. 3. What is there about your job that you feel you cannot do? 4. Many people feel as you do, but they learn to dress and act and work just like they did before the surgery. ANS: 3 Open-ended questions without prejudgment or belittling encourage the patient to identify sources of anxiety and help the patient cope with, adapt to, or problem-solve stressful events. PTS: REF: TOP: KEY: MSC: 1 DIF: Cognitive Level: Comprehension 407, Nursing Care Plan OBJ: 2 Interpersonal Communication Skills Nursing Process Step: Implementation NCLEX: Psychosocial Integrity
8. The nurse explains to a preoperative patient that a J-pouch anal anastomosis procedure has the primary advantage of: 1. no odor. 2. easier to irrigate. 3. near-normal bowel elimination. 4. less problem with diarrhea. ANS: 3 Preoperative teaching includes the expectation of near-normal bowel elimination. As with any bowel elimination, there will be odor and possibly occasional diarrhea. There is no need for an irrigation. PTS: 1 DIF: Cognitive Level: Comprehension REF: 401 OBJ: 2 TOP: Preoperative Teaching for J-pouch KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 9. In postoperative teaching to a ureterotomy patient, the nurse would include information pertaining to: 1. significance of ureteral catheter for the first week. 2. appropriate use of karaya gum products. 3. daily pouch change schedule. 4. changing pouch in the evening before bedtime. ANS: 1 Information about the ureteral catheter, which will be in place for the first week, is important. Karaya gum products are not used for urinary appliances because urine breaks down the karaya. Pouches are changed only every 4 to 6 days to prevent skin irritation. The pouch is best changed in the morning.
PTS: OBJ: KEY: MSC:
1 DIF: Cognitive Level: Application REF: 412 4 TOP: Postoperative Teaching to Ureterotomy Patient Nursing Process Step: Planning NCLEX: Health Promotion and Maintenance
10. An ostomate asks the nurse what limitations must be observed in the immediate postoperative period when at home. The most informative information that the nurse can share is: 1. avoidance of heavy lifting for at least 3 months. 2. limit fluid intake to no more than 1000 mL/day. 3. wear loose clothing, without belts or elastic. 4. cover your appliance with plastic sheeting while showering. ANS: 1 Avoidance of heavy lifting for 3 months is advised. Ostomates should take in at least 2000 mL of fluid every day. They may wear ordinary clothes that dont bind the stoma. Showering is allowed, because the appliance is waterproof. PTS: REF: TOP: KEY: MSC: 1 DIF: Cognitive Level: Application 401, Patient Teaching Plan OBJ: 7 Postoperative Limitations for Ostomates Nursing Process Step: Implementation NCLEX: Physiological Integrity
11. The colostomy patient continues to worry about odor. The nurse can help allay those concerns by explaining that odor: 1. only occurs when changing the colostomy appliance. 2. is caused by certain foods that can be omitted from the diet. 3. is mainly caused by poor hygiene and can be remedied. 4. is far more noticeable to the patient than to others. ANS: 2 The problem of odor is a frequent cause of anxiety to the colostomy patient. Gas is the main cause of odor production. Omission of gas-causing foods can reduce gas and odor, mainly by the trial and error method. Odor is noticeable to both the patient and others. PTS: OBJ: KEY: MSC: 1 DIF: Cognitive Level: Application REF: 403-404 7 TOP: Controlling Odor from a Colostomy Nursing Process Step: Implementation NCLEX: Psychosocial Integrity
12. Common surgeries to divert urine may include cutaneous ureterostomy, ileal conduit, and ureteroileostomy. In developing a nursing care plan for any of these patients, the concept that is common to them all is that: 1. a ureterostomy is smaller and lighter in color than an intestinal stoma and urine drainage is expected to be expelled through the stoma continuously. 2. the drainage pouch is cleaned with sterile water and soap only, regardless of how foul the odor has become. 3. the patient should be encouraged to drink about 750 mL water daily. 4. the urine will leak through the pouch at night, so care must be taken to protect the bedclothes.
ANS: 1 To develop an effective plan of care, the nurse must be knowledgeable about surgical procedures and expected outcomes. PTS: 1 DIF: Cognitive Level: Comprehension REF: 409 OBJ: 6 TOP: Care Plan Development KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 13. The nurse caring for a 2-day postoperative colostomy patient should report immediately if a stoma is assessed as: 1. beefy and red. 2. having swelling. 3. having a small amount of bleeding around it. 4. blue-tinged. ANS: 4 A stoma should be beefy red. Blue or black coloration is an indication of poor circulation and should be reported immediately. Swelling and a small amount of blood around the stoma are normal in early postoperative days. PTS: 1 DIF: Cognitive Level: Application REF: 398 OBJ: 4 TOP: Stoma Assessment in Colostomy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 14. A baby born without a urinary bladder has a cutaneous ureterostomy with one stoma and a cutaneous ureterostomy has been surgically created. There is one stoma. Discussion with the childs family regarding care should include which of the following? 1. This urinary diversion is permanent and urine will drain from it continuously. 2. In the future, there will be a second surgery to offer an exit for the urine from the other kidney. 3. This pouch needs to be changed only about once a week. 4. You should notify the surgeon if the stoma becomes paler in color. ANS: 1 The babys ureterostomy and drainage of urine are constant. This is a permanent solution because of the lack of a bladder. Both ureters are joined for urine release through the stoma. The pouch will be on continuously and needs to be changed as needed several times a day. PTS: OBJ: TOP: KEY: MSC: 1 DIF: Cognitive Level: Application REF: 409 5 Congenital Indications and Outcomes for Cutaneous Ureterostomy Nursing Process Step: Implementation NCLEX: Health Promotion and Maintenance
15. The initial assessment of a patient just returned from surgery for creation of an Indiana pouch would include: 1. drainage of urine from the Penrose drain at the operative site. 2. the condition and color of the stoma 3. the appearance of mucus in the urine.
4. copious and odorous urine drainage from the incision. ANS: 1 Indiana pouches initially have a drain Penrose to drain the small amount of urine; it will have mucus in it, but no odor. There is no stoma to observe. Irrigations may be necessary to remove clots and mucus. PTS: OBJ: KEY: MSC: 1 DIF: Cognitive Level: Analysis REF: 413 3 TOP: Assessment of New Postoperative Patient Nursing Process Step: Evaluation NCLEX: Safe, Effective Care Environment
16. The patient says, I hate this yucky paste under my appliance. I think I will just tape it on. The nurses most informative response to this remark would be which of the following? 1. Taping will not work! 2. Taping will not seal the wafer tight enough to prevent leakage or fill in creases. 3. Taping with waterproof tape is just as effective as the paste. 4. Taping is far more irritating to the skin than the paste would be. ANS: 2 Reminding that the paste both bonds and waterproofs is the best information. PTS: OBJ: KEY: MSC: 1 DIF: Cognitive Level: Comprehension REF: 409 7 TOP: Function of Paste on Ostomy Appliance Nursing Process Step: Implementation NCLEX: Psychosocial Integrity
17. The patient comes to the industrial nurse and is frantic because the stoma to the colostomy has prolapsed after 1 year postsurgery. The nurses best counsel would be which of the following? 1. If there are still feces coming from the stoma, it is not blocked. Contact your surgeon for an evaluation. 2. You must come in immediately, because the stoma may completely retract into your abdomen. 3. This is an emergency situation, because it has stenosed. 4. Dont worry about that. Coughing or sneezing might have caused the prolapse. It will come back out in a few hours. ANS: 1 The prolapse of a stoma is very disturbing to a client. The condition should be evaluated by the surgeon, but if the stoma is still patent, there is no need for emergency implementation. Prolapse can be caused by coughing or sneezing, but the stoma will still need evaluation. PTS: 1 DIF: Cognitive Level: Comprehension REF: 405 OBJ: 7 TOP: Stomal Prolapse KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 18. A patient is receiving discharge instructions. He shares with the nurse that he intends to do a lot of traveling. Instructions for travel should include which of these points? 1. Pack plenty of extra colostomy supplies in your checked airline luggage. Some
places you might visit do not always carry those supplies you will need. 2. Exercise caution with new foods, especially local fruits and vegetables, because they may cause diarrhea or gas. 3. If visiting somewhere where drinking local water is not advised, it is still all right to irrigate the colostomy with the local water. 4. Repeat back to me what we just talked about so that you will be sure and remember carefully everything you have been taught. ANS: 2 Warning about foods in a different country is appropriate. Supplies should be placed in a carry-on bag for quick access or in the case of lost luggage. Water that is not safe to drink is not appropriate as irrigation fluid. PTS: OBJ: KEY: MSC: 1 DIF: Cognitive Level: Application 7 TOP: Discharge Instructions Nursing Process Step: Implementation NCLEX: Physiological Integrity REF: 412
19. The nurse caring for the immediate postoperative patient with an ileal conduit should report and/or intervene for: 1. lack of bowel sounds. 2. distended abdomen. 3. mucus present in the urine. 4. small amount of blood in the drainage. ANS: 2 The distended abdomen suggests that the GI suction is not effective to prevent bowel distention. The nurse must check the efficiency of the suction. Lack of bowel sounds, mucus in the urine, and a small amount of blood in the drainage is to be expected as normal postoperative assessments. PTS: 1 DIF: Cognitive Level: Application REF: 412 OBJ: 3 TOP: Postoperative Care of Ileal Conduit KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 20. The patient asks if rectal suppositories can be used to assist with constipation problems with his colostomy. The nurse clarifies that suppositories: 1. can be used in double-barreled colostomies. 2. cannot be used in a stoma. 3. should not ever be used in a colostomy. 4. will not penetrate well enough to relieve constipation. ANS: 2 Suppositories can be used effectively in double-barreled colostomies and in stomas of a single colostomy. PTS: OBJ: KEY: MSC: 1 DIF: Cognitive Level: Application 7 TOP: Use of Rectal Suppositories Nursing Process Step: Implementation NCLEX: Physiological Integrity REF: 408
21. The nurse identifies an electrolyte imbalance in a preoperative ileostomy patient based on the laboratory values of: 1. Na+, 144 mEq/L; K+, 5 mEq/L; HCO3, 26 mEq/L; poor tissue turgor. 2. Na+, 140 mEq/L; K+, 4.5 mEq/L; HCO3, 28 mEq/L; no nausea or vomiting, request for pain analgesic q5hr. 3. Na+, 160 mEq/L; K+, 2.5 mEq/L; HCO3, 18 mEq/L; confused, and weak. 4. Hct, 41 mL/dL; Hgb, 11 g/dL; WBC, 8000/mm3; shallow rapid respirations. ANS: 3 Normal values of electrolytes are Na+ = 140 mEq/L, K+ = 5 mEq/L, HCO3 = 27 mEq/L. PTS: 1 DIF: Cognitive Level: Analysis REF: 399 OBJ: 2 TOP: Signs of Electrolyte Imbalance KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 22. The best nursing strategy for encouraging ostomy patient self-care would be to: 1. plan to change the pouch when family members will be present, have the patient watch, and listen to the procedure. 2. frequently tell the patient that if he or she does not learn stoma self-care, no one is going to do it for them. 3. encourage the patient to watch the stoma care procedure, gradually encouraging participation. 4. shield the patient from sight of the stoma until the patient actually asks to see it. ANS: 3 The goal for teaching ostomates is to assist them to care for themselves without pressure or forcing. PTS: REF: TOP: KEY: MSC: 1 DIF: Cognitive Level: Analysis 407, Nursing Care Plan OBJ: 4 Implementing the Teaching Plan to Encourage Self-Care Nursing Process Step: Implementation NCLEX: Safe, Effective Care Environment
23. The nurse clarifies that the condition that would necessitate an ostomy would be: 1. tumor obstructing the digestive tract lumen. 2. congenital absence of one ureter. 3. chronic diarrhea. 4. fracture of the pelvis and pubis. ANS: 1 Obstructions in the GI tract are common indications for a colostomy. PTS: 1 DIF: Cognitive Level: Knowledge REF: 396 OBJ: 1 TOP: Indications for Ostomy Surgery KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 24. The nurse cautions that some adhesive pouch material used to hold the appliance in place may cause:
1. 2. 3. 4.
melting of the pouch. excoriation of the stoma. an allergic reaction. unpleasant odor.
ANS: 3 Pouch adhesive can cause allergic reactions, but does not melt the pouch or cause odor. Because the paste is not in contact with the stoma, it does not affect the stoma. PTS: 1 DIF: Cognitive Level: Application REF: 399 OBJ: 3 TOP: Responses of Body, Stoma, to Pouch Materials KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 25. The most effective way for a nurse to help provide support to the ostomate patient who has ineffective regimen management is to: 1. ask a volunteer from the American Cancer Society or United Ostomy Association to visit. 2. ask a volunteer from the Reach for Recovery Society to visit. 3. send a close family member for psychiatric counseling. 4. obtain humor books pertaining to illness, such as Anatomy of an Illness, or watch several episodes of Three Stooges on TV. ANS: 1 Contact with persons who have coped with all the aspects of ostomies are excellent resources for the persons with new ostomies. Every effort is made to send a volunteer of the same age and gender. PTS: OBJ: KEY: MSC: 1 DIF: Cognitive Level: Comprehension 4, 6 TOP: Support for Ostomy Patients Nursing Process Step: Implementation NCLEX: Psychosocial Integrity REF: 397
MULTIPLE RESPONSE 1. The postoperative colostomy ostomate is at risk for loss of fluid volume and electrolyte imbalance. The assessments that indicate such loss are (select all that apply): 1. changing mental status. 2. twitching. 3. poor skin turgor. 4. dry mucous membranes. 5. edema. ANS: 1, 2, 3, 4, 5 All the options are indicators for fluid and electrolyte loss. The loss of base products from the bowel that allow for metabolic acidosis can be a very serious postoperative complication. PTS: 1 DIF: Cognitive Level: Analysis REF: 399 OBJ: 4 TOP: Assessments for Fluid and Electrolyte Loss KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
2. The nurse instructs the patient to be diligent in cleaning fecal matter from around the stoma because the fecal matter can cause (select all that apply): 1. fungal infection. 2. bacterial infection. 3. yeast infection. 4. deterioration of the stoma. 5. odor. ANS: 1, 2, 3, 5 Fecal matter left on the skin and trapped under the pouch can cause fungal, bacterial, and yeast infections as well as odor. PTS: OBJ: KEY: MSC: 1 DIF: Cognitive Level: Analysis 4 TOP: Cleaning Stoma of Fecal Matter Nursing Process Step: Implementation NCLEX: Health Promotion and Maintenance REF: 399
3. The 1-day postoperative ileostomy patient is concerned about the fact that there has been no drainage from the ileostomy. The nurse reminds the patient that (select all that apply): 1. the drainage does not start until about 24 to 48 hours postsurgery. 2. the first drainage will have blood in it. 3. mucus will be obvious in the early drainage. 4. the first drainage is expelled with a great deal of force. 5. a large amount of flatus will accompany the first drainage. ANS: 1, 2, 3 Drainage does not begin because of the empty bowel prior to surgery. The first drainage appears 24 to 48 hours postsurgery and is accompanied by small amounts of blood and mucus from the bowel. The first drainage is expelled with low pressure and very little, if any, gas. PTS: OBJ: KEY: MSC: 1 DIF: Cognitive Level: Analysis REF: 398 1 TOP: Expected Drainage from an Ileostomy Nursing Process Step: Implementation NCLEX: Physiological Integrity
4. The nurse counsels that complications of the continent pouches (Kock and Indiana) may be (select all that apply): 1. incontinence. 2. difficult catheterization. 3. pyelonephritis. 4. rupture of the pouch. 5. peritonitis. ANS: 1, 2, 3 The most frequent complications are incontinence, difficult catheterization, and reflux pyelonephritis. Rupture and peritonitis are not threats to the patient from this surgery. PTS: 1 OBJ: 7 DIF: Cognitive Level: Analysis REF: 413 TOP: Complication of Kock and Indiana Continent Pouches
KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity