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 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?
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.
Question 2 of 5
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?
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.
Question 3 of 5
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?
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.
Question 4 of 5
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?
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.
Question 5 of 5
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?
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.