Nokea
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.
You may also like to solve these questions
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.
The nurse is caring for a client who has undergone colostomy. Which of the following instructions should the nurse include in the teaching plan?
- A. Restrict traveling by air.
- B. Limit outdoor activities.
- C. Avoid light clothing.
- D. Chew food well.
Correct Answer: D
Rationale: The nurse should instruct a client who has undergone colostomy to chew food properly. This helps decrease gas that results chiefly from swallowing air rather than from digestion. The client need not limit or avoid travel or outdoor activities. If traveling by air, the nurse should instruct the client to take ostomy supplies in carry-on luggage to prevent their loss if luggage is misdirected or lost. If the client requires firm, light support, he or she should find a stoma shield to help prevent irritation or undue pressure on the stoma.
A client who is scheduled for an ileostomy surgery and been taking corticosteroids is instructed to taper the drug, eventually discontinuing it. The nurse would monitor this client for which of the following?
- A. Cerebral anoxia
- B. Cardiac dysrhythmias
- C. Hypothyroidism
- D. Adrenal insufficiency
Correct Answer: D
Rationale: Adrenal crisis is potentially life-threatening and may result from the abrupt withdrawal of corticosteroids. Therefore, the nurse should closely monitor a client who is scheduled for an ileostomy surgery for adrenal insufficiency, resulting from corticosteroid withdrawal. Withdrawal of corticosteroids does not cause cerebral anoxia, cardiac dysrhythmias, or hypothyroidism.
A client will be having a total colectomy in 4 days. The client does not have an obstruction. What does the nurse anticipate instructing the client about doing prior to the surgery to prepare the bowel?
- A. Instructing the client about dietary restrictions and lavage agents
- B. Making sure the client drinks 2 L of fluids prior to the procedure
- C. Instructing the client to have no food except clear liquids for 4 days
- D. There will be no special preparation, and the client may eat until midnight the night prior to surgery.
Correct Answer: A
Rationale: Cleansing of the bowel before surgery is carried out using dietary restriction in combination with laxative or lavage agents, depending on the client's condition (i.e., presence or absence of obstruction) and according to the surgeon's preference. There are no benefits to the client drinking 2 L of fluids prior to the procedure or taking in only clear liquids for 4 days.
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.