Nokea
A client has been discharged from the acute care facility with an ileostomy. The client comes to the clinic for a follow-up visit and informs the nurse that the wound has been draining and they are having abdominal pain and running a fever. What does the nurse suspect is occurring with the client?
- A. The client is having an allergic reaction to the appliance.
- B. The client has developed anemia from blood loss.
- C. The client has developed a wound infection.
- D. The client is not emptying the pouch correctly.
Correct Answer: C
Rationale: Signs of wound infection are wound drainage, abdominal pain, and elevated temperature. These symptoms do not indicate an allergic reaction, anemia, or not emptying the pouch correctly.
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The nurse is caring for a client who is to undergo surgery for the creation of a continent ileostomy. Which statement by the client indicates the nurse's teaching has been successful?
- A. I'll need to empty the appliance more frequently.'
- B. I'll need to learn how to empty the reservoir several times a day.'
- C. My stool will be loose initially but then become formed in a week or so.'
- D. If I just push on the valve and the drainage will flow out easily.'
Correct Answer: B
Rationale: A continent ileostomy involves the creation of an internal reservoir for the storage of GI effluent. It stores the effluent for several hours until the client removes it with a catheter. Initially, the reservoir is emptied every 2 to 4 hours, and then three to four times per day as the capacity of the reservoir increases (usually in about 6 months). This reservoir eliminates the need to wear an external appliance. Stool will continue to be liquid at all times. A continent ileostomy does have a nipple valve through which a catheter is inserted to drain the reservoir.
A nurse is preparing to administer the prescribed vitamin B12 to a client who has had most of his ileum removed. The nurse understands that this is necessary for which reason?
- A. Prevents thrombosis
- B. Prevents deficiencies
- C. Aids proper digestion
- D. Prevents constipation
Correct Answer: B
Rationale: Parenteral injections or intranasal administrations of vitamin B12 are used to prevent deficiencies in clients who have had most or all of the ileum removed because this area is responsible for B12 absorption. Vitamin B12 does not prevent thrombosis or constipation or aid digestion.
A client who is scheduled for an ileostomy surgery says to the nurse, 'I'm afraid I won't be able to look at that stoma.' Which response by the nurse would be most therapeutic?
- A. That's something you don't have to think about now.'
- B. I'll make sure there is a familiar nurse here with you the first time.'
- C. It's okay, everybody feels this anxious about this.'
- D. Don't worry, I'm sure that you will be able to do this just fine.'
Correct Answer: B
Rationale: Telling the client that a familiar nurse will be with him the first time provides the client with reassurance that he will not be alone and will have the support of a familiar person to answer questions and provide comfort and support. Telling the client not to worry about it now, that everybody feels anxious, and that he'll do just fine discounts the client's feelings and is not therapeutic.
A male client, age 32 years, was recently married, and he and his wife would like to have children. The client is scheduled to have a total colectomy and is concerned with being able to have children. What is the best answer given by the nurse related to the client's concern?
- A. There is no risk of you not being able to father children after this surgery.'
- B. Certainly understand your concern, but there are other options such as artificial insemination with a donor.'
- C. You may want to consider collection and storing of sperm for later use if you are planning to have children.'
- D. Infertility is a side effect of this surgery and should be considered carefully.'
Correct Answer: C
Rationale: Young male clients may wish to collect and store sperm for later use if they plan to have children. Sexual dysfunction in men after a total colectomy is unusual but sometimes occurs. If such dysfunction persists after a colectomy, operative and nonoperative options are available to facilitate erection.
Which intervention would be most appropriate for a client who has undergone colostomy surgery?
- A. Monitoring vital signs once a day.
- B. Taking temperature by rectal route
- C. Monitoring the volume of gastric secretions.
- D. Minimizing the client's fluid intake
Correct Answer: C
Rationale: The nurse should monitor the volume of suctioned gastric secretions in a client who has undergone colostomy surgery. The nurse should monitor vital signs once every 4 hours and take temperature by any route other than rectal. The nurse should also ensure that the client's fluid intake is adequate and not minimized.