Nokea
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.
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A client with an ileostomy tells the nurse that he is having a lot of problems with the formation of gas. What can the nurse tell the client to help her with this a common issue?
- A. Eat slowly and chew food well with mouth closed.
- B. Restrict fluids.
- C. Administer an enema to clear out the stool.
- D. Dilate the stoma.
Correct Answer: A
Rationale: The client should eat slowly and chew food well with the mouth closed to help lessen the development of gas. Restricting oral intake should only be done with medical supervision and will not help with gas reduction. Enemas should not be administered. The stoma is only dilated when the stool volume decreases.
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 who is scheduled for an ileostomy surgery says to the nurse, 'I'm afraid I won't be able to look at that stoma.' Which response by the nurse would be most therapeutic?
- A. That's something you don't have to think about now.'
- B. I'll make sure there is a familiar nurse here with you the first time.'
- C. It's okay, everybody feels this anxious about this.'
- D. Don't worry, I'm sure that you will be able to do this just fine.'
Correct Answer: B
Rationale: Telling the client that a familiar nurse will be with him the first time provides the client with reassurance that he will not be alone and will have the support of a familiar person to answer questions and provide comfort and support. Telling the client not to worry about it now, that everybody feels anxious, and that he'll do just fine discounts the client's feelings and is not therapeutic.
A client is preparing to have colorectal surgery and will have a colostomy created temporarily in hopes that he may be able to have it reversed in 6 months. The client is very concerned about the care of the colostomy. What preoperative interaction would the client benefit from?
- A. Discussing other options with the surgeon
- B. Meeting with an enterostomal therapist
- C. Going to a support group with other clients that have colostomies
- D. Watching a video about colostomies
Correct Answer: B
Rationale: Clients benefit from preoperative interactions with a specially certified nurse, referred to as an enterostomal therapy nurse, enterostomal therapist, or wound, ostomy, and continence nurse. This nurse assists with marking placement of the stoma and collaborates with the surgeon regarding placement and the client's educational needs. Other options may not be available for this client, especially if there is a tumor present. Going to a support group would be a good option in the postoperative management because the client should be given information from the professional prior to going to surgery. Watching the video with the therapist and having the option to answer questions would be a better choice than watching it alone.
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.