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Colostomy By Rnpedia.com

34 Questions
Colostomy By Rnpedia.com

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Questions and Answers
  • 1. 
    Arthur Cruz, a 45 year old artist, has recently had an abdominoperineal resection and colostomy. Mr. Cruz accuses the nurse of being uncomfortable during a dressing change, because his “wound looks terrible.” The nurse recognizes that the client is using the defense mechanism known as:
    • A. 

      Reaction Formation

    • B. 

      Sublimation

    • C. 

      Intellectualization

    • D. 

      Projection

  • 2. 
    When preparing to teach a client with colostomy how to irrigate his colostomy, the nurse should plan to perform the procedure:
    • A. 

      When the client would have normally had a bowel movement

    • B. 

      After the client accepts he had a bowel movement

    • C. 

      Before breakfast and morning care

    • D. 

      At least 2 hours before visitors arrive

  • 3. 
    When observing an ostomate do a return demonstration of the colostomy irrigation, the nurse notes that he needs more teaching if he:
    • A. 

      Stops the flow of fluid when he feels uncomfortable

    • B. 

      Lubricates the tip of the catheter before inserting it into the stoma

    • C. 

      Hangs the bag on a clothes hook on the bathroom door during fluid insertion

    • D. 

      Discontinues the insertion of fluid after only 500 ml of fluid has been instilled

  • 4. 
    When doing colostomy irrigation at home, a client with colostomy should be instructed to report to his physician :
    • A. 

      Abdominal cramps during fluid inflow

    • B. 

      Difficulty in inserting the irrigating tube

    • C. 

      Passage of flatus during expulsion of feces

    • D. 

      Inability to complete the procedure in half an hour

  • 5. 
    A client with colostomy refuses to allow his wife to see the incision or stoma and ignores most of his dietary instructions. The nurse on assessing this data, can assume that the client is experiencing:
    • A. 

      A reaction formation to his recent altered body image.

    • B. 

      A difficult time accepting reality and is in a state of denial.

    • C. 

      Impotency due to the surgery and needs sexual counseling

    • D. 

      Suicide thoughts and should be seen by psychiatrist

  • 6. 
    The nurse would know that dietary teaching had been effective for a client with colostomy when he states that he will eat:
    • A. 

      Food low in fiber so that there is less stool

    • B. 

      Everything he ate before the operation but will avoid those foods that cause gas

    • C. 

      Bland foods so that his intestines do not become irritated

    • D. 

      Soft foods that are more easily digested and absorbed by the large intestines

  • 7. 
    The nurse is caring for a male client postoperatively following creation of a colostomy. Which nursing diagnosis should the nurse include in the plan of care?
    • A. 

      Sexual dysfunction

    • B. 

      Body image, disturbed

    • C. 

      Fear related to poor prognosis

    • D. 

      Nutrition: more than body requirements, imbalanced

  • 8. 
    The nurse is performing a colostomy irrigation on a male client. During the irrigation, the client begins to complain of abdominal cramps. What is the appropriate nursing action?
    • A. 

      Notify the physician

    • B. 

      Stop the irrigation temporarily

    • C. 

      Increase the height of the irrigation

    • D. 

      Medicate for pain and resume the irrigation

  • 9. 
    The nurse is teaching a female client how to perform a colostomy irrigation. To enhance the effectiveness of the irrigation and fecal returns, what measure should the nurse instruct the client to do?
    • A. 

      Increase fluid intake

    • B. 

      Place heat on the abdomen

    • C. 

      Perform the irrigation in the evening

    • D. 

      Reduce the amount of irrigation solution

  • 10. 
    The nurse is caring for a client with a colostomy. The client tells the nurse that he makes small pin holes in the drainage bag to help relieve gas. The nurse should teach him that this action:
    • A. 

      Destroys the odor-proof seal

    • B. 

      Wont affect the colostomy system

    • C. 

      Is appropriate for relieving the gas in a colostomy system

    • D. 

      Destroys the moisture barrier seal

  • 11. 
    A Client is scheduled to have a descending colostomy. He’s very anxious and has many questions regarding the surgical procedure, care of stoma, and lifestyle changes. It would be most appropriate for the nurse to make a referral to which member of the health care team?
    • A. 

      Social worker

    • B. 

      Registered dietician

    • C. 

      Occupational therapist

    • D. 

      Enterostomal nurse therapist

  • 12. 
    SITUATION: Michiel, A male patient diagnosed with colon cancer was newly put in colostomy. Michiel shows the BEST adaptation with the new colostomy if he shows which of the following?
    • A. 

      Look at the ostomy site

    • B. 

      Participate with the nurse in his daily ostomy care

    • C. 

      Ask for leaflets and contact numbers of ostomy support groups

    • D. 

      Talk about his ostomy openly to the nurse and friends

  • 13. 
    The nurse plans to teach Michiel about colostomy irrigation. As the nurse prepares the materials needed, which of the following item indicates that the nurse needs further instruction?
    • A. 

      Plain NSS / Normal Saline

    • B. 

      K-Y Jelly

    • C. 

      Tap water

    • D. 

      Irrigation sleeve

  • 14. 
    The nurse should insert the colostomy tube for irrigation at approximately  
    • A. 

      1-2 inches

    • B. 

      3-4 inches

    • C. 

      6-8 inches

    • D. 

      12-18 inches

  • 15. 
    • A. 

      5 inches

    • B. 

      12 inches

    • C. 

      18 inches

    • D. 

      24 inches

  • 16. 
    Which of the following behavior of the client indicates the best initial step in learning to care for his colostomy?  
    • A. 

      Ask to defer colostomy care to another individual

    • B. 

      Promises he will begin to listen the next day

    • C. 

      Agrees to look at the colostomy

    • D. 

      States that colostomy care is the function of the nurse while he is in the hospital

  • 17. 
    • A. 

      Stop the irrigation by clamping the tube

    • B. 

      Slow down the irrigation

    • C. 

      Tell the client that cramping will subside and is normal

    • D. 

      Notify the physician

  • 18. 
    The next day, the nurse will assess Michiel’s stoma. The nurse noticed that a prolapsed stoma is evident if she sees which of the following?
    • A. 

      A sunken and hidden stoma

    • B. 

      A dusky and bluish stoma

    • C. 

      A narrow and flattened stoma

    • D. 

      Protruding stoma with swollen appearance

  • 19. 
    Michiel asked the nurse, what foods will help lessen the odor of his colostomy. The nurse best response would be  
    • A. 

      Eat eggs

    • B. 

      Eat cucumbers

    • C. 

      Eat beet greens and parsley

    • D. 

      Eat broccoli and spinach

  • 20. 
    The nurse will start to teach Michiel about the techniques for colostomy irrigation. Which of the following should be included in the nurse’s teaching plan?
    • A. 

      Use 500 ml to 1,000 ml NSS

    • B. 

      Suspend the irrigant 45 cm above the stoma

    • C. 

      Insert the cone 4 cm in the stoma

    • D. 

      If cramping occurs, slow the irrigation

  • 21. 
    The nurse knew that the normal color of Michiel’s stoma should be
    • A. 

      Brick Red

    • B. 

      Gray

    • C. 

      Blue

    • D. 

      Pale Pink

  • 22. 
    Nurse Michelle should know that the drainage is normal 4 days after a sigmoid colostomy when the stool is:
    • A. 

      Green liquid

    • B. 

      Solid formed

    • C. 

      Loose, bloody

    • D. 

      Semiformed

  • 23. 
    • A. 

      Solid.

    • B. 

      Semi-mushy.

    • C. 

      Mushy.

    • D. 

      Fluid.

  • 24. 
    When irrigating a colostomy, the nurse lubricates the catheter and gently inserts it into the stoma no more than _______ inches
    • A. 

      3”

    • B. 

      2”

    • C. 

      4”

    • D. 

      5”

  • 25. 
    Discharge instructions for a patient who has been operated on for colorectal cancer include irrigating the colostomy. The nurse knows her teaching is effective when the patient states he’ll contact the doctor if:
    • A. 

      He experiences abdominal cramping while the irrigant is infusing

    • B. 

      He has difficulty inserting the irrigation tube into the stoma

    • C. 

      He expels flatus while the return is running out

    • D. 

      He’s unable to complete the procedure in 1 hour

  • 26. 
    The first day after, surgery the nurse finds no measurable fecal drainage from a patient’s colostomy stoma. What is the most appropriate nursing intervention?
    • A. 

      Call the doctor immediately.

    • B. 

      Obtain an order to irrigate the stoma.

    • C. 

      Place the patient on bed rest and call the doctor.

    • D. 

      Continue the current plan of care.

  • 27. 
    Before discharge, the nurse scheduled the client who had a colostomy for colorectal cancer for discharge instruction about resuming activities. The nurse should plan to help the client understands that:
    • A. 

      After surgery, changes in activities must be made to accommodate for the physiologic changes caused by the operation.

    • B. 

      Most sports activities, except for swimming, can be resumed based on the client’s overall physical condition.

    • C. 

      With counseling and medical guidance, a near normal lifestyle, including complete sexual function is possible.

    • D. 

      Activities of daily living should be resumed as quickly as possible to avoid depression and further dependency.

  • 28. 
    The client who had transverse colostomy asks the nurse about the possible effect of the surgery on future sexual relationship. What would be the best nursing response?
    • A. 

      The surgery will temporarily decrease the client’s sexual impulses.

    • B. 

      Sexual relationships must be curtailed for several weeks.

    • C. 

      The partner should be told about the surgery before any sexual activity.

    • D. 

      The client will be able to resume normal sexual relationships.

  • 29. 
    Tony returns form surgery with permanent colostomy. During the first 24 hours the colostomy does not drain. The nurse should be aware that:
    • A. 

      Proper functioning of nasogastric suction

    • B. 

      Presurgical decrease in fluid intake

    • C. 

      Absence of gastrointestinal motility

    • D. 

      Intestinal edema following surgery

  • 30. 
    A temporary colostomy is performed on the client with colon cancer. The nurse is aware that the proximal end of a double barrel colostomy:
    • A. 

      Is the opening on the client’s left side

    • B. 

      Is the opening on the distal end on the client’s left side

    • C. 

      Is the opening on the client’s right side

    • D. 

      Is the opening on the distal right side

  • 31. 
    • A. 

      Hold the syringe 18 inches above the stoma and administer the feeding slowly

    • B. 

      Pour 30 ml of water before and after feeding administration

    • C. 

      Insert the ostomy feeding tube 1 inch towards the stoma

    • D. 

      A Pink stoma means that circulation towards the stoma is all well

  • 32. 
    A client is scheduled to undergo an abdominal perineal resection with a permanent colostomy. Which of the following measures would be an anticipated part of the client’s preoperative care?
    • A. 

      Keep the client NPO for 24 hrs before surgery

    • B. 

      Administer neomycin sulfate the evening before surgery

    • C. 

      Inform the client that total parenteral nutrition will likely be implemented after surgery

    • D. 

      Advise the client to limit physical activity

  • 33. 
    A 58-year-old male client tells the office nurse that his wife does not let him change his colostomy bag himself. Which response by the nurse indicates as understanding of the situation?
    • A. 

      "Your wife's need to help you is a reality you should accept"

    • B. 

      "Do you think your wife might benefit from counseling?"

    • C. 

      "You feel you need privacy when changing your colostomy?"

    • D. 

      "Have you discussed the situation with your doctor?"

  • 34. 
    A male client with bladder cancer has had the bladder removed and an ileal conduit created for urine diversion. While changing this client’s pouch, the nurse observes that the area around the stoma is red, weeping, and painful. What should nurse Katrina conclude?
    • A. 

      The skin wasn’t lubricated before the pouch was applied.

    • B. 

      The pouch faceplate doesn’t fit the stoma.

    • C. 

      A skin barrier was applied properly.

    • D. 

      Stoma dilation wasn’t performed.