Nokea
The nurse is caring for a client in the immediate postoperative phase after having a colostomy created. What type of appliance should the nurse use at this time?
- A. A reusable pouch appliance should be used.
- B. A disposable or temporary appliance should be used.
- C. A dry sterile dressing should be used over the stoma.
- D. A wet to dry dressing should be used over the stoma to keep it moist.
Correct Answer: B
Rationale: A disposable, or temporary, appliance is preferred in the immediate postoperative phase because the size of the stoma changes over time as a result of swelling from the procedure itself. The size of the stoma may change rapidly and differ from one appliance change to the next. After the stoma heals and reaches its final size and shape, a permanent appliance (reusable) may be used. A dry sterile dressing or wet to dry dressing should not be placed over the stoma due to the saturation of stool, which may cause maceration of the skin around the stoma.
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The nurse is providing ostomy care to the client with an ileostomy. What can the nurse use to promote adhesion of the ostomy appliance?
- A. Adhesive glue
- B. Tincture of Benzoin
- C. Vaseline
- D. Karaya paste
Correct Answer: D
Rationale: Karaya paste, which becomes gelatinous when in contact with moisture, is commonly used in place of an adhesive. Karaya paste promotes adhesion of the ostomy appliance.
A client who will be having a portion of colon removed and colostomy created informs the nurse that he 'will not be attractive any longer.' The nurse determines the nursing diagnosis is Altered Body Image Perception related to the stoma and altered bowel elimination. What expected outcome related to this diagnosis will the client have?
- A. The client will be given instructions on how to care for the ostomy.
- B. The client will demonstrate adequate coping skills.
- C. The client will be allowed time and support to promote communication.
- D. Client verbalizes what the changes will be and the benefits to future health.
Correct Answer: D
Rationale: For a nursing diagnosis of Altered Body Image Perception, the expected outcome is that the client verbalizes what the changes will be and the benefits to future health. This demonstrates that the client understands and is accepting of the changes that are to occur. Giving instructions is a nursing intervention and not an outcome. Demonstrating adequate coping skills is not a measurable goal, and supporting and promoting communication does not correlate with the nursing diagnosis of Altered Body Image Perception.
A client scheduled for a total colectomy has been taking the immunosuppressive agent, azathioprine. As part of the nurse's preoperative teaching, when should the client be told to discontinue the medication to prevent negative effects on tissue healing?
- A. 3 days before surgery
- B. 1 week before surgery
- C. 1 month before surgery
- D. 3 months before surgery
Correct Answer: C
Rationale: Immunosuppressive agents such as azathioprine, 6-mercaptopurine, and cyclosporine should be discontinued 3 to 4 weeks before surgery to prevent negative effects on tissue healing. Aspirin-containing compounds are discontinued at least 1 week before surgery to decrease the risk of bleeding.
The nurse is preparing to irrigate a client's single-barrel colostomy after surgery. The nurse would expect an order from the healthcare provider to irrigate the colostomy on what day after surgery?
- A. Fourth or fifth postoperative day
- B. The day after surgery
- C. The seventh postoperative day
- D. The colostomy should be irrigated immediately postop
Correct Answer: A
Rationale: Colostomy irrigation begins on the fourth or fifth postoperative day. Standard irrigation is a scheduled irrigation, using 500 to 1500 mL of tepid water.
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.