ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 48 : Caring for Clients With Ostomies Questions
Question 1 of 5
The nurse is caring for a client who has undergone colostomy. Which of the following instructions should the nurse include in the teaching plan?
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.
Question 2 of 5
A client has had surgery to create an ileoanal reservoir. Which instruction would the nurse give to reduce the risk for bowel incontinence?
Correct Answer: C
Rationale:
To reduce the risk for bowel incontinence, the nurse should instruct a client who has undergone ileoanal reservoir surgery to perform perineal exercises. The client need not avoid high-protein food, take walks, or perform warm water soaks because these do not minimize the risk of bowel incontinence.
Question 3 of 5
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?
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.
Question 4 of 5
The nurse is caring for a client who is to undergo surgery for the creation of a continent ileostomy. Which statement by the client indicates the nurse's teaching has been successful?
Correct Answer: B
Rationale: A continent ileostomy involves the creation of an internal reservoir for the storage of GI effluent. It stores the effluent for several hours until the client removes it with a catheter. Initially, the reservoir is emptied every 2 to 4 hours, and then three to four times per day as the capacity of the reservoir increases (usually in about 6 months). This reservoir eliminates the need to wear an external appliance. Stool will continue to be liquid at all times. A continent ileostomy does have a nipple valve through which a catheter is inserted to drain the reservoir.
Question 5 of 5
The nurse is assessing the stool consistency of a client with an ascending colostomy. Which of the following would the nurse expect to find?
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.