and answers rated A+
The nurse is assessing a client with bladder cancer who had a cystectomy
and creation of a ureteros- tomy. Which statement by the client indicates the
need for more education about urinary stoma care?
a. "I change my pouch every week."
b. "I change the appliance in the morning."
c. "I empty the urinary collection bag when it is two-thirds full."
d. "When I'm in the shower, I direct the flow of water away from my stoma." -
correct answers c. "I empty the urinary collection bag when it is two-thirds full."
rationale:
The urinary collection bag needs to be changed when it is one-third full to
prevent pulling of the appliance and leakage. The remaining options identify
correct state- ments about the care of a urinary stoma.
The nurse is providing care for a client with ulcerative colitis who underwent
the creation of a transverse colostomy. Which observation requires immediate
notification of the surgeon?
a. Stoma is beefy red and shiny.
b. Stoma has a purple discoloration.
c. Skin excoriation is noted around the stoma.
d. Semiformed stool is noted in the ostomy pouch. - correct answers b. Stoma
has a purple discoloration.
, rationale:
Ischemia of the stoma would be associated with a dusky or bluish or purple
color. A beefy red and shiny stoma is normal and expected. Skin excoriation
needs to be addressed and treated but does not require as immediate
attention as purple discoloration of the stoma. Semiformed stool is a normal
finding.
A client with ulcerative colitis had a new colostomy created 2 days earlier and
is beginning to pass malodorous flatus from the stoma. What is the correct
interpretation by the nurse?
a. This is a normal, expected event.
b. The client is experiencing early signs of ischemic
bowel.
c. The client should not have the nasogastric tube removed.
d. This indicates inadequate preoperative bowel preparation. - correct
answers a. This is a normal, expected event.
rationale:
As peristalsis returns following creation of a colostomy, the client begins to
pass malodorous flatus. This indicates returning bowel function and is an
expected event. Within 72 hours of surgery, the client should begin passing
stool via the colostomy. Options 2, 3, and 4 are incorrect interpretations.
A client with Crohn's disease has judt has surgery to create an ileostomy. The
nurse assesses the client in the postoperative period for which most frequent
complication of this type of surgery?
a. Folate deficiency
b. Malabsorption of fat