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The nurse is caring for a patient with ulcerative colitis who underwent a proctocolectomy with an ileostomy. Which of the following information should the nurse include in patient teaching?
- A. Restrict fluid intake to prevent constant liquid drainage from the stoma.
- B. Use care when eating high-fibre foods to avoid obstruction of the ileum.
- C. Irrigate the ileostomy daily.
- D. Change the pouch every day to prevent leakage of contents onto the skin.
Correct Answer: B
Rationale: High-fibre foods are introduced gradually and should be well chewed to avoid obstruction of the ileostomy. Patients with ileostomies lose the absorption of water in the colon and need to take in increased amounts of fluid. The pouch should be drained frequently but is changed every 5-7 days. The drainage from an ileostomy does not require daily irrigation.
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The nurse is caring for a patient with an acute exacerbation of ulcerative colitis having 14-16 bloody stools a day and crampy abdominal pain associated with the diarrhea. Which of the following actions should the nurse take?
- A. Place the patient on NPO status.
- B. Administer IV metoclopramide.
- C. Teach the patient about total colectomy surgery.
- D. Administer cobalamin injections.
Correct Answer: A
Rationale: An initial therapy for an acute exacerbation of inflammatory bowel disease (IBD) is to rest the bowel by making the patient NPO. Cobalamin (vitamin B12) is absorbed in the ileum, which is not affected by ulcerative colitis. Although total colectomy is needed for some patients, there is no indication that this patient is a candidate. Metoclopramide increases peristalsis and will worsen symptoms.
The nurse is admitting a patient for evaluation of right lower quadrant abdominal pain accompanied by nausea and vomiting. On assessment the temperature is 37.5°C (99.5°F), heart rate 105, respiratory rate 20 and an O2 saturation of 90%. Which of the following actions should the nurse take?
- A. Check for rebound tenderness.
- B. Assist the patient to cough and deep breathe.
- C. Administer oxygen via nasal cannula.
- D. Encourage the patient to take sips of clear liquids.
Correct Answer: C
Rationale: The patient's clinical manifestations are consistent with appendicitis but the main priority is to administer oxygen as the O2 saturation is only 90%. The patient should be NPO in case immediate surgery is needed. Checking for rebound tenderness frequently is unnecessary and uncomfortable for the patient. The patient will need to know how to cough and deep breathe postoperatively, but coughing will increase pain at this time.
During the initial postoperative assessment of a patient's stoma formed from a transverse colostomy, the stoma appearance indicates good circulation to the stoma. Which of the following actions should the nurse take based upon these findings?
- A. Document the stoma assessment
- B. Assess the stoma every 30 minutes
- C. Notify the surgeon about the stoma
- D. Place an ice pack on the stoma to reduce swelling
Correct Answer: A
Rationale: The stoma appearance indicates good circulation to the stoma. There is no indication that surgical intervention is needed or that frequent stoma monitoring is required. Swelling of the stoma is normal for 2-3 weeks after surgery, and an ice pack is not needed.
The nurse is providing discharge teaching for a patient with a new colostomy. Which of the following patient actions indicates that the teaching has been effective?
- A. Empties the colostomy bag once it is one-third full.
- B. Drinks at least 1000 mL of fluid a day.
- C. Contacts the health care provider if there is pain or erythema in the peristomal area.
- D. Takes acetaminophen when a temperature of 38.3°C is present.
Correct Answer: C
Rationale: The health care provider should be contacted if there is pain or erythema in the peristomal area. If the patient has a temperature, the health care provider should be contacted. The colostomy should be emptied before it becomes one-third full. The patient should drink at least 1500-2000 mL per day to avoid dehydration.
Which of the following nursing actions is most important to include in the plan of care for a patient who had an abdominal-perineal resection the previous day?
- A. Teach about a low-residue diet.
- B. Monitor output from the stoma.
- C. Assess the perineal drainage and incision.
- D. Encourage acceptance of the colostomy stoma.
Correct Answer: C
Rationale: Because the perineal wound is at high risk for infection, the initial care is focused on assessment and care of this wound. Teaching about diet is best done closer to discharge from the hospital. There will be very little drainage into the colostomy until peristalsis returns. The patient will be encouraged to assist with the colostomy, but this is not the highest priority in the immediate postoperative period.