Nokea
The nurse is preparing a client for surgery and observes on the operative permit that the client will be having a double-barrel colostomy. The nurse explains to the client's spouse that this is performed on what portion of the large intestine?
- A. Descending
- B. Ascending
- C. Transverse
- D. Sigmoid
Correct Answer: C
Rationale: A double-barrel colostomy, which is performed most often in the transverse section of the large intestine, contains both a proximal and distal stoma.
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The nurse is discussing care of the client's ileostomy and is instructing the client to avoid certain medications that move through without being absorbed. What medications should the client avoid? Select all that apply.
- A. Enteric-coated products
- B. Liquid medication
- C. Slow-release beads
- D. Layered tablets
- E. Chewable tablets
Correct Answer: A,C,D
Rationale: Clients with an ileostomy should avoid enteric-coated products and some modified-release drugs, such as slow-release beads and layered tablets. These products may pass through without being absorbed. The client may take liquid and chewable tablets because they will go through the breakdown process in the stomach.
The nurse is assessing the stool consistency of a client with an ascending colostomy. Which of the following would the nurse expect to find?
- A. Liquid
- B. Liquid to pasty
- C. Soft
- D. Formed
Correct Answer: B
Rationale: The consistency of fecal material ranges from semiliquid to formed depending on the area from which the colostomy is formed. With an ascending colostomy, stool would be liquid to pasty. An ileostomy would produce liquid stool, a transverse colostomy would produce soft stool; a sigmoid colostomy would produce formed stool.
The nurse is teaching the client post ileostomy surgery about attachment of the faceplate around the stoma. What measure will ensure secure attachment of the pouch to the peristomal skin?
- A. Apply a large quantity of adhesive around the stoma prior to attaching the faceplate.
- B. Press the adhesive faceplate around the stoma for about 30 seconds.
- C. Press the adhesive faceplate from the outward edge of the stoma inward.
- D. Wipe the faceplate with alcohol to remove debris.
Correct Answer: B
Rationale: Press the adhesive faceplate around the stoma for about 30 seconds. This measure ensures secure attachment of the pouch to the peristomal skin. A large amount of adhesive is not necessary to adhere the faceplate around the stoma. The adhesive faceplate should be pressed from the stomal edge outward. The faceplate should not be wiped with alcohol first.
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 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.