Question 1 of 6
Report content error
Which intervention would the nurse perform upon observing a bright red stoma that protrudes above the skin, with slight bleeding for a patient who had a colostomy 2 days ago?
-
- Calling the health care providerIt is not necessary to call the health care provider.
- Correct
- Documenting these as expected findingsThe nurse would document these normal findings. Immediately after surgery, the ostomy should be a bright red; it would protrude slightly above the skin level, and it would bleed slightly.
-
- Preparing the patient to return to surgeryIt is not necessary to prepare the patient to return to surgery.
-
- Placing ice on the stoma to reduce swellingIce would never be placed on the stoma because ice would cause vasoconstriction and prevent blood flow to the site.
Question 2 of 6
Report content error
The nurse is discussing peristomal skin care. Which statement indicates the nurse needs further education?
-
- Appliances should be changed frequently to maintain an effective seal.Appliances should be changed every 2 to 3 days to maintain an effective seal.
-
- Ileostomy drainage can be highly damaging to the skin.The drainage contains enzymes and bile salts that are highly damaging to the skin.
- Correct
- In humid weather, a blow dryer on high can help with drying the skin.Placing the dryer on high can burn the skin and cause damage. Placing it on the lowest setting can help dry the skin in humid weather.
-
- When the appliance is changed, it should be patted dry.This is accurate because rubbing the skin can cause trauma.
Question 3 of 6
Report content error
A nurse is educating a patient with an ostomy about ways to control odor. Which statement made by the patient requires further education?
-
- “I will avoid eating beans and legumes.”Avoiding foods known to cause odor or gas, such as beans and legumes, is helpful to control odor.
- Correct
- “I will eat a diet of green, leafy vegetables.”A diet high in green, leafy vegetables can cause more odorous gas, increasing the odor in the bag.
-
- “I will eliminate sauerkraut and cabbage from my diet.”Eliminating foods known to cause odor or gas, such as sauerkraut and cabbage, from one’s diet is helpful to control odor.
-
- “I can place a deodorizing tablet in the bag.”Deodorizing sprays and tablets can be put in the bag to reduce odor.
Question 4 of 6
Report content error
Which measure is appropriate if for a patient suspected of having an intestinal blockage? Select all that apply. One, some, or all responses may be correct.
-
- Take a laxative.The patient should never take a laxative because it can cause the body to lose more water.
- Correct
- Begin a liquid diet.A liquid diet will ensure there is not further formed stool accumulating proximal to the blockage.
- Correct
- Take oral enzymes.Oral digestive enzymes will help with digestion, so the blockage does not worsen.
-
- Lavage the ileostomy.If lavage is required, it must be completed by a licensed professional.
- Correct
- Take a warm bath.A heating pad or warm bath may help encourage relaxation of the abdominal muscles.
Question 5 of 6
Report content error
What underlying process does the nurse suspect when caring for a patient with severe diarrhea who developed a rectal fistula?
-
- Ulcerative colitis (UC)With UC, inflammation doesn’t spread through the full thickness of the bowel wall, so fistulas are less likely to form.
- Correct
- Crohn diseaseCrohn disease is suspected if a fistula is accompanied by diarrhea because 50% of patients with Crohn disease develop a rectal fistula.
-
- HemorrhoidsHemorrhoids are inflamed blood vessels that often occur after constipation.
-
- Pilonidal sinusA pilonidal sinus or cyst can occur after an injury, improper cleaning or the area, and obesity, but the development of a fistula is uncommon.
Question 6 of 6
Report content error
The nurse is educating a patient on care of an ileal stoma. Which statement indicates a need for further teaching?
- Correct
- “The surgeon will place a dressing over my new stoma.”A surgical dressing is never placed over an ileal stoma because output is continuous.
-
- “I will be on antibiotics for a short time.”Antibiotic therapy is usually given for the first 24 hours postoperatively for microbial prophylaxis.
-
- “The output from my stoma will be continuous.”Output from an ileostomy is continuous. The fecal output for a colostomy does not occur for 2 to 4 days because of the preoperative bowel evacuation, possible ileus, and clear liquid diet postoperatively.
-
- “My stoma should be a pink or deep red color.”A pink or deep red color is the normal appearance of a stoma. A dark purple or black stoma would be concerning for an issue with blood flow.