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25 Cards in this Set
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1. An artificial opening into a body cavity is a/an:
1. gastrostomy. 2. ostomy. 3. colonoscopy. 4. ureterostomy. |
Topic: Terminology
Nursing Process Step: N/A Objective: 3 Cognitive Level: Knowledge NCLEX: N/A Correct Answer: 2 Rationale: An ostomy is an artificial opening into a body cavity. Text Reference: 347 |
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2. The nurse assigned to morning medications observes the following four drugs listed for an ileostomy patient. Which one would prompt the nurse to question before administration?
1. Allegra (time-released) per mouth 2. Ampicillin per IV 3. Heparin per subcutaneous injection 4. Aspirin per mouth 2. The nurse assigned to morning medications observes the following four drugs listed for an ileostomy patient. Which one would prompt the nurse to question before administration? 1. Allegra (time-released) per mouth 2. Ampicillin per IV 3. Heparin per subcutaneous injection 4. Aspirin per mouth |
Topic: Medications to Ostomates
Nursing Process Step: Planning Objective: 4 Cognitive Level: Application NCLEX: Physiological Integrity Correct Answer: 1 Rationale: Ostomy patients are not given oral time-release forms of medications because the medication may be excreted through the pouch before it is absorbed. Text Reference: 352 |
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3. A 47-year-old patient is 3 days postop with a permanent colostomy. He reports some abdominal discomfort. In making the initial physical assessment this morning, the nurse makes the following observations. Which of the following findings is reported to the RN/charge nurse as soon as possible?
1. vital signs: temperature 100; pulse, 92; blood pressure, 120/64 2. stoma is swollen and red; small amount of blood at base 3. pouch drainage of 110 cc green-brown liquid, oozing from pouch edges 4. skin 3” around stoma is red with greenish drainage |
Topic: Prioritizing Actions Based on Physical Assessment Findings
Nursing Process Step: Intervention Objective: 4 Cognitive Level: Application NCLEX: Physiological Integrity Correct Answer: 4 Rationale: Signs of infection around the stoma should be reported immediately. Text Reference: 349 |
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4. Which of these statements are accurate in describing concerns of female ostomates?
1. The female with an ileostomy who is no longer able to control fecal matter and the associated odors most often needs extended counseling by a psychiatrist. 2. While peers in their 20s are having babies, this patient must face the fact that she can never have her own child because of the ileostomy stoma. 3. The cultural significance of an ileostomy may be unique for each individual and is best assessed by open-ended comments and the nurse’s nonjudgmental listening skills. 4. Women of any age are not reluctant to learn self-care. |
Topic: Interpersonal Communication Techniques
Nursing Process Step: N/A Objective: 4,7 Cognitive Level: Knowledge NCLEX: Psychosocial Integrity Correct Answer: 3 Rationale: Open-ended questions and careful listening without pre-judgment encourage the patient to identify sources of anxiety. Text Reference: 351 |
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5. In order to assure a good fit of the appliance to avoid leakage, what factors should be considered for stoma placement?
1. patient’s pre-operative diet preferences and dislikes 2. medications taken regularly, regular clothing styles 3. usual patterns of patient’s skin healing ability 4. location of bony prominences, umbilicus |
Topic: Placement of the Stoma
Nursing Process Step: N/A Objective: 2 Cognitive Level: Knowledge NCLEX: N/A Correct Answer: 4 Rationale: Location of the stoma must allow space for the appliance to be secured. Skin folds, bony prominences, and the location of the navel affect the fit. Text Reference: 347 |
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6. Adequate nutrition is vital for good health and healing. In assisting a colostomy patient choose an appropriate menu 2 weeks postop, the nurse would encourage the patient to choose which of the following?
1. roast beef, mashed potatoes, peeled stewed tomatoes 2. broiled pork chop, boiled potato, corn on the cob 3. broiled trout, mashed potatoes, spinach 4. BBQ on white bun, coleslaw, French fries |
Topic: Ostomy Nutrition Teaching
Nursing Process Step: Planning Objective: 7 Cognitive Level: Analysis NCLEX: Physiological Integrity Correct Answer: 1 Rationale: Gas forming or spicy foods and roughage usually cause gas and usually diarrhea. Successful independent living is best established by teaching practical means of coping. Text Reference: 352 |
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7. A patient is having an emergency colostomy after trauma received in a car accident. Although the physician has talked to him about the surgery, the nurse will reinforce this teaching and provide support for management of this condition. Which of the following is an important understanding to convey to this patient?
1. “This is only a temporary adjustment for you and the colostomy will be gone in a few days.” 2. "Personally, I can’t deal with the looks and smell of that thing, but a nurse with special training will be in to help you." 3. "I see you are looking out the window at the sky. Will you share with me what you are thinking about?" 4. “Do you want another pain shot so that I can change the dressing without you having to look at it?” |
Topic: Interpersonal Communication Skills
Nursing Process Step: Intervention Objective: 2 Cognitive Level: Comprehension NCLEX: Psychosocial Integrity Correct Answer: 3 Rationale: Open-ended questions without pre-judgment encourage the patient to identify sources of anxiety, and promote patients ability to cope with, adapt to, or problem solve stressful events. Text Reference: 357 |
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8. The correct term for an ostomy to drain fecal material from the intestines is:
1. gastrostomy or colonoscopy. 2. colostomy or ureterostomy. 3. ileostomy or colostomy. 4. ureterostomy or colostomy. |
Topic: Pre-operative Teaching
Nursing Process Step: Planning Objective: 1, 2 Cognitive Level: Knowledge NCLEX: Health Promotion and Maintenance Correct Answer: 3 Rationale: Pre-op teaching includes instructor’s use of correct terminology. Text Reference: 354 |
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9. Identify a nursing diagnosis that requires particular attention for patients with ostomies of the digestive tract in addition to anxiety related to anticipated changes in self-image and which of the following?
1. Deficient knowledge of what to expect postoperatively 2. Impaired swallowing related to muscle weakness 3. Risk for disuse syndrome related to neurological damage 4. Risk for injury related to disorientation |
Topic: Identifying Priority Nursing Diagnoses
Nursing Process Step: Planning Objective: 4 Cognitive Level: Knowledge NCLEX: Psychosocial Integrity Correct Answer: 1 Rationale: Meeting basic patient needs includes reducing anxiety, especially through sharing with the patient what to expect in the near future. Text Reference: 349 |
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10. A cutaneous ureterostomy patient and a colostomy patient are assigned for care. Similarities in their care include which of the following?
1. Medications must never be administered via the rectal route. 2. Karaya products are used as skin protection. 3. Patients do not need to wear a medical alert device. 4. The first sign of patient acceptance of the ostomy is looking at the stoma. |
Topic: Ostomate Similarities
Nursing Process Step: N/A Objective: 6 Cognitive Level: Application NCLEX: Physiological Integrity Correct Answer: 4 Rationale: Adjustment to body image, which has been altered by the ostomy, takes place in different stages for different patients. There are known steps to this acceptance. Text Reference: 351 |
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11. The nursing diagnosis of Risk for infection related to stoma contamination includes planned assessment/ intervention of which of the following nursing actions?
1. Observe changes in vital sign values (blood pressure, temperature, and pulse) and change of usual drainage amount, color, and consistency. 2. Observe for increased gas being passed, leaking pouch, and decreasing interest in self-care. 3. Observe for patent IV site without redness or tenderness, but change the site as a precaution. 4. Auscultate for sounds immediately next to stoma site, use rectal temperatures. |
Topic: Prioritizing Nursing Actions When Infection Is Suspected
Nursing Process Step: Intervention Objective: 4 Cognitive Level: Application NCLEX: Physiological Integrity Correct Answer: 1 Rationale: The risk for stoma contamination and infection is a major complication with known signs that nurses should be aware of and continually assess. Changing values of vital signs is one of the first signs to be observed. Although the other distractors are reasonable actions, they do not relate directly to contamination/infection of the stoma site. Text Reference: 359 |
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12. Common surgeries to divert urine may include cutaneous ureterostomy, ileal conduit, and ureteroileostomy. In developing a nursing care plan for these patients, which of the following statements is common to all of them?
1. An ureterostomy is smaller and lighter in color than an intestinal stoma and urine drainage is to expected to be expelled through the stoma continuously. 2. The drainage pouch is cleaned with sterile water and soap only, regardless of how foul the odor has become. 3. The patient should be encouraged to drink about 750 cc water daily. 4. The urine will leak through the pouch at night, so care must be taken to protect the bedclothes. |
Topic: Care Plan Development
Nursing Process Step: Planning Objective: 6 Cognitive Level: Comprehension NCLEX: Physiological Integrity Correct Answer: 1 Rationale: To develop an effective plan the nurse must be knowledgeable of correct planned interventions and alternative actions. Text Reference: 361 |
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13. The postoperative patient with a new continent ileostomy is potentially at risk for several complications. Nursing care of this patient should include provision for ongoing assessment of which the following conditions, with related nursing action?
1. Risk of dehydration related to inadequate oral intake. Nursing intervention: Keep strict I/O and offer up to 2000 cc water or juice daily. Check for tissue turgor, nausea, vomiting, or confusion. 2. Risk of ureteral obstruction related to inflammation or infection, or skin separation of the stoma. Nursing intervention: Check dressings for blood or drainage, assess stoma, check vital signs for changes, check I/O. 3. Risk of infection of stoma related to electrolyte imbalance. Nursing intervention: Check for lab values, push oral fruit juices, wash stoma with vinegar solution frequently, change pouch tid. 4. Risk of lack of skin integrity, related to NG tube displacement, or nares excoriation. Nursing intervention: Cleanse facial area frequently, apply skin protectant to nares and taped areas, assess the NG tube gastric placement, and irrigate NG tube as ordered. |
Topic: Intervention of Appropriate Care Based on Accurate Assessments
Nursing Process Step: Intervention Objective: 6 Cognitive Level: Analysis NCLEX: Physiological Integrity Correct Answer: 4 Rationale: Risk of inflammation or infection may be lessened by appropriate assessments and nursing actions. Text Reference: 352 |
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14. A baby was born without a urinary bladder, and a cutaneous ureterostomy has been surgically created. There is one stoma. A fact that can be discussed with his caregiver as the pouch changing takes place is which of the following?
1. “This urinary diversion is permanent because there is no other way for the urine to come out of his body.” 2. “Someday the surgeon will have to operate to drain the other kidney, so this is only temporary.” 3. “This pouch needs to be changed only about once a week.” 4. “Joe’s condition will interfere greatly with schoolwork, sports, and play with friends as he grows older.” |
Topic: Congenital Indications and Outcomes for Cutaneous Ureterostomy
Nursing Process Step: Intervention Objective: 5 Cognitive Level: Application NCLEX: Health Promotion and Maintenance Correct Answer: 1 Rationale: The baby’s ureterostomy is permanent because this lack of a bladder is a condition with which he was born. He will have the potential of a normal life in every other aspect except the urinary diversion. Text Reference: 358 |
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15. The initial assessment of a patient just returned from surgery for creation of a neobladder should include which of these expectations?
1. There is a beefy red stoma in the right lower quadrant. 2. There is a small, pale blue stoma in the left upper quadrant. 3. There is no stoma to observe. 4. There is copious odorous urine drainage from the incision. |
Topic: Assessment of New Postoperative Patient
Nursing Process Step: Evaluation Objective: 3 Cognitive Level: Analysis NCLEX: Safe, Effective Care Environment Correct Answer: 3 Rationale: Neobladder does not create a stoma. Text Reference: 359 |
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16. To prepare a patient preoperatively for a permanent ileostomy, the nurse implements the care plan by:
1. administering several enemas of 1000 cc so that the patient can feel this volume. 2. showing the patient the various appliances that will be in use, such as pouches, tubes, and odor-eliminating techniques. 3. assuring the patient that only sterile technique will be used in changing the pouch. 4. encouraging the patient to openly discuss the expected loss of sexual ability. |
Topic: Preoperative Preparation
Nursing Process Step: Intervention Objective: 2 Cognitive Level: Comprehension NCLEX: Psychosocial Integrity Correct Answer: 2 Rationale: Becoming familiar with various appliances will ease patient anxiety and stimulate questions from the patient. Text Reference: 351 |
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17. Creating an ileoanal reservoir is a procedure that provides for fecal diversion from ileum to the rectum. The ability to care for this patient includes which of the following skills for the LPN?
1. collaborate with other health team members developing a care plan 2. keep sterile and use strict isolation technique at all times 3. provide a single person room, limit visitors, except clergy 4. position on left side to lessen pressure on the operative site |
Topic: Planning with the Health Team for Total Effective Care
Nursing Process Step: Planning Objective: 6 Cognitive Level: Comprehension NCLEX: Physiological Integrity Correct Answer: 1 Rationale: The Nursing Care Plan that includes input from all the members of the care team who will implement it provides for optimum planned safe effective care. Text Reference: 353 |
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18. A patient is receiving discharge instructions. He shares with the nurse that he intends to do a lot of traveling. Instructions for travel should include which of these points?
1. “Pack plenty of extra colostomy supplies in your airline luggage. Some areas do not always carry those supplies you will need.“ 2. “Exercise caution with new foods, especially their local fruits and vegetables, because they may cause diarrhea or gas.” 3. “If visiting where drinking local water is not advised, it is still all right to irrigate the colostomy with the local water.” 4. “Remember carefully everything you have been taught; written instructions are sure to be lost or misplaced.” |
Topic: Discharge Instructions
Nursing Process Step: Intervention Objective: 7 Cognitive Level: Application NCLEX: Physiological Integrity Correct Answer: 2 Rationale: Teaching the patient how to include care adaptations when resuming intended lifestyle. Text Reference: 352 |
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19. Ostomy surgery provides for diversion of fecal material with each of the following procedures. Which stoma will divert the most formed stool?
1. ileostomy 2. jejunostomy 3. colostomy 4. duodenostomy |
Topic: Characteristics of Ostomy
Nursing Process Step: Assessment Objective: 3 Cognitive Level: Application NCLEX: Physiological Integrity Correct Answer: 3 Rationale: The longer the bolus is in the intestinal tract, the more formed the stool becomes. Text Reference: 347 |
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20. Risk for deficient fluid volume after ileostomy surgery is a complication that will have known signs of the impending problems. The correct nursing intervention based upon assessment would be:
1. Examine IV site for redness or discomfort, if none, change IV site. 2. Check I/O, carefully measuring NG tube drainage, IV intake; compare to stoma drainage and urine volume. Report changes. 3. Check stoma drainage for increased urine, maintain NPO status. 4. Observe for copious gas. Repeat daily stoma irrigation, 1000 cc NS. |
Topic: Complications of Ileostomy
Nursing Process Step: Intervention Objective: 4 Cognitive Level: Analysis NCLEX: Physiological Integrity Correct Answer: 2 Rationale: Deficient fluid volume in ileostomy patient may be caused by a combination of NG drainage, increased urine output, copious intestinal drainage, or vomiting. Text Reference: 352 |
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21. Risk for electrolyte imbalance in a preoperative ileostomy patient includes which of the following signs/symptoms?
1. poor tissue turgor, decreased blood pressure, 6 am lab wnl 2. no nausea or vomiting, request for pain analgesic q 5 hr 3. Na+ 160, K+ 2.5, HCO3 18, confused, and weak 4. Hct. 41; Hgb. 11; WBC. 8,000. shallow rapid respirations |
Topic: Signs of Electrolyte Imbalance
Nursing Process Step: Assessment Objective: 2 Cognitive Level: Analysis NCLEX: Physiological Integrity Correct Answer: 3 Rationale: To differentiate between significant signs/symptoms appropriate to the risk identified. Text Reference: 353 |
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22. The best strategy for encouraging ostomy patient self-care would be to:
1. plan to change the pouch when family members will be present, have the patient watch, and listen to the procedure. 2. frequently tell the patient that if he or she does not learn stoma self care, no one is going to do it for them. 3. encourage the patient to watch the stoma care procedure, gradually encouraging participation. 4. shield the patient from sight of the stoma until the patient actually asks to see it. |
Topic: Implementing the Teaching Plan to Encourage Self Care
Nursing Process Step: Intervention Objective: 4 Cognitive Level: Analysis NCLEX: Safe, Effective Care Environment Correct Answer: 3 Rationale: The goal for teaching ostomates is to assist them to be able to provide safe, efficient care for themselves. Text Reference: 357 |
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23. Which of the conditions below would necessitate an ostomy?
1. tumor obstructing the digestive tract lumen 2. congenital absence of one ureter 3. placement of a feeding tube into the stomach 4. an auto accident in which the iliac and pubic bones are fractured |
Topic: Indications for Ostomy Surgery
Nursing Process Step: N/A Objective: 1 Cognitive Level: Knowledge NCLEX: N/A Correct Answer: 1 Rationale: Obstructions in the GI tract are common indications for a colostomy. Text Reference: 355 |
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24. Adhesive pouch material used to hold the appliance in place may cause:
1. diarrheic response in the patient. 2. an unpleasant odor. 3. an allergic reaction. 4. rapid skin breakdown. |
Topic: Responses of Body, Stoma, to Pouch Materials
Nursing Process Step: Evaluation Objective: 3 Cognitive Level: Application NCLEX: Physiological integrity Correct Answer: 3 Rationale: Fecal drainage into a pouch may cause care problems. Text Reference: 350 |
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25. Based on an assessment of ineffective therapeutic regimen management, which is the best way of providing support to the ostomy patient?
1. Ask a volunteer from the American Cancer Society or United Ostomy Association to visit. 2. Ask a volunteer from the Reach for Recovery Society to visit. 3. Send a close family member for psychiatric counseling. 4. Obtain humor books pertaining to illness, such as Anatomy of an Illness, or watch several episodes of Three Stooges on TV. |
Topic: Support for Ostomy Patients
Nursing Process Step: Intervention Objective: 4, 6 Cognitive Level: Comprehension NCLEX: Psychosocial Integrity Correct Answer: 1 Rationale: Contact with persons who have coped with all the aspects of ostomies are excellent resources for the persons with new ostomies. Text Reference: 356 |
