Nokea
The nurse is instructing a client with an ileostomy on appliance and changing it. What statement made by the client demonstrates the client understands using a new appliance for the first time?
- A. I will patch test it first on nonirritated skin at the inner side of my forearm.'
- B. I can expect the new appliance to sting or itch for the first 24 hours.'
- C. When changing the appliance and faceplate, I should scrub vigorously to remove all debris.'
- D. I should change the faceplate every 8 hours.'
Correct Answer: A
Rationale: When using a new adhesive product, the client should patch test it first on nonirritated skin at the inner aspect of the forearm. The most common causes of discomfort are reactions to the adhesive or solvent used to remove it or irritation from leaking fecal drainage. In such cases, the client may experience stinging, tingling, or itching immediately after an appliance change. If a sensation is prolonged or intensified, the client should remove the appliance regardless of whether it has been on for 1 hour or several days. The client should avoid rubbing, which may further irritate skin. If the faceplate is changed too frequently, skin around the stoma may become raw and excoriated secondary to removal of protective layers of epithelium with the faceplate.
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The nurse is caring for a client about to have the first stage of an ileoanal anastomosis. What should the nurse inform the client they will experience?
- A. Solid stool from the anus
- B. Very little discharge from the anus
- C. Control of the fecal material from the anus
- D. Continuous discharge of mucus from the anus
Correct Answer: D
Rationale: After the first stage of surgery, clients experience an almost continuous discharge of mucus from the anus and a frequent discharge of fecal material from the ileostomy. Initially, clients cannot control the frequent watery discharge.
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.
A client is having a procedure that will remove the entire colon and rectum and will bring the end of the ileum through a separate area on the right lower quadrant of the abdomen. What type of procedure does the nurse understand this client will be having?
- A. Appendectomy
- B. Total colectomy
- C. Double-barrel colostomy
- D. Abdominoperineal resection
Correct Answer: B
Rationale: In the usual surgical procedure for a conventional ileostomy, the entire colon and rectum are removed (total colectomy). The terminal end of the ileum is brought out through a separate area on the right lower quadrant of the abdomen slightly below the umbilicus, near the outer border of the rectus muscle. The end is averted and sutured to the skin, a process referred to as a matured stoma. An appendectomy is removal of the appendix. A double-barrel colostomy may be a temporary colostomy for rest of the bowel. Abdominoperineal resection removes the anus, rectum, and part of the sigmoid colon.
A client is to have a total colectomy and has been on prednisone for 6 months for the treatment of Crohn disease. What medication does the nurse anticipate administering in the preoperative phase to prevent adrenal crisis?
- A. Intravenous hydrocortisone
- B. Intravenous antibiotics
- C. Blood transfusion
- D. A low-molecular-weight heparin
Correct Answer: A
Rationale: A preoperative 'stress' IV steroid (e.g., hydrocortisone) is given to clients who have been on prednisone within the previous 6 months to prevent adrenal crisis. Antibiotics, blood transfusions, and low-molecular-weight heparin are not typically used to prevent adrenal crisis in this context.
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.