Nokea
A nurse prepares to assist a patient with a newly created ileostomy. Which recommended patient teaching points would the nurse stress? Select all that apply.
- A. When you inspect the stoma, it should be dark purple-blue.
- B. The size of the stoma will stabilize within 2 weeks.
- C. Keep the skin around the stoma site clean and moist.
- D. The stool from an ileostomy is normally liquid.
- E. Eat dark-green vegetables to control the odor of the stool.
- F. You may have a tendency to develop food blockages.
Correct Answer: D,E,F
Rationale: Ileostomy stool is liquid (D), dark-green vegetables reduce odor (E), and food blockages are a risk (F). The stoma should be pink/red, not purple-blue (A), stabilizes in 4-6 weeks, not 2 (B), and skin should be clean and dry, not moist (C).
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A nurse is caring for an older adult who reports persistent constipation and has a number of laxative prescriptions on the MAR. Which medication would the nurse avoid for this patient?
- A. Saline osmotic laxative
- B. Bulk-forming laxative
- C. Methylcellulose
- D. Stool softener
Correct Answer: A
Rationale: Saline osmotic laxatives (A) can cause fluid/electrolyte imbalances in older adults, especially with kidney or cardiac issues, and should be avoided. Bulk-forming (B, C) and stool softeners (D) are safer options.
A nurse is assisting a patient to change an ostomy appliance when they note the stoma is protruding into the bag. What would be the nurse's first action in this situation?
- A. Reassuring the patient that this is a normal with a new ostomy
- B. Notifying the health care provider that the stoma is prolapsed
- C. Having the patient rest for 30 minutes to see if the prolapse resolves
- D. Replacing the appliance with a larger appliance
Correct Answer: C
Rationale: A protruding stoma suggests prolapse; the first action is having the patient rest for 30 minutes (C) to see if it resolves. Reassuring (A) is incorrect as prolapse isn't normal, notifying the provider (B) is premature, and a larger appliance (D) doesn't address the issue.
A nurse is administering a large-volume cleansing enema to a patient prior to surgery. When the enema solution is introduced, the patient reports severe cramping. What nursing intervention would the nurse perform next?
- A. Elevating the head of the bed 30 degrees and repositioning the rectal tube
- B. Placing the patient in a supine position and modifying the amount of solution
- C. Lowering the solution container and checking the temperature and flow rate
- D. Removing the rectal tube and notifying the primary care provider
Correct Answer: C
Rationale: Severe cramping during an enema suggests the solution is too cold or the flow rate is too fast. Lowering the container and checking temperature and flow rate (C) addresses this. Elevating the bed (A) or changing position (B) doesn't resolve cramping, and removing the tube (D) is premature.
A nurse plans to administer a retention enema to a patient with a fecal impaction. Which nursing action is appropriate for this procedure?
- A. Administering a large volume of solution (500 to 1,000 mL)
- B. Mixing milk and molasses in equal parts for an enema
- C. Instructing the patient to retain the enema for at least 30 minutes
- D. Administering the enema while the patient is sitting on the toilet
Correct Answer: C
Rationale: Retention enemas require the patient to hold the solution for at least 30 minutes (C) to soften stool. Large volumes (A) are for cleansing enemas, milk and molasses (B) are for carminative enemas, and administering on the toilet (D) prevents retention.
A community health nurse is providing an adult education session about colon cancer. Which signs and symptoms of this cancer will the nurse include? Select all that apply.
- A. Blood in the stool
- B. Previous colonoscopy
- C. Passing two large bowel movements daily
- D. Unintentional weight loss
- E. Upper abdominal cramping
- F. Previous opioid use
Correct Answer: A,D
Rationale: Colon cancer symptoms include blood in the stool (A) and unintentional weight loss (D). Previous colonoscopy (B) and opioid use (F) are not symptoms, two large bowel movements (C) are normal, and upper abdominal cramping (E) is less specific.