. A affected person is two days publish-decide from an ileostomy placement. Which finding
calls for instantaneous nursing movement?
A. The stoma is excreting liquid stool.
B. The patient's potassium level is two.Zero
C. The stoma is bright red and moist.
D. The patient reports mucoid drainage from the anus. - ANS-The solution is B. A affected
person with an ileostomy is at danger for electrolyte imbalances. The nurse should display
the affected person (specially after ileostomy surgical operation) for those imbalances. A
normal potassium is 3.5 to 5.1. Therefore, a stage of two.Zero requires instantaneous
nursing movement. The nurse must contact the medical doctor for in addition orders. All the
other alternatives are everyday findings observed with an ileostomy.
Thirteen. Which sort of colostomy can permit a affected person to have bowel continence?
A. Descending or Sigmoid Colostomy
B. Ascending or Transverse Colostomy
C. Transverse or Descending Colostomy
D. Ascending or Descending Colostomy - ANS-The solution is A. Patients with a colostomy
in places most distal within the GI music have the highest hazard of bowel continence (as a
result, discover ways to manipulate their bowel actions).
A affected person has a double-barrel colostomy of the transverse colon. You observe on
evaluation two stomas, a proximal and distal stoma. What sort of stool do you anticipate to
drain from the proximal and distal stomas?
A. Proximal: lose to partially fashioned stool; Distal: mucous
B. Proximal: liquid stool; Distal: mucous
C. Proximal: mucous; Distal: lose to partially shaped stool
D. Proximal & Distal: lose to partially fashioned stool - ANS-A. Proximal: lose to in part
shaped stool; Distal: mucous
The solution is A. The proximal will drain stool at the same time as the distal will NOT. The
distal will drain mucous. Since it is a double-barrel colostomy of the transverse colon, you
could count on the stool to be lose to partly formed.
A patient is eight hours put up-choose from an colostomy placement. Which locating
requires immediate nursing movement?
A. The stoma is swollen and massive.
B. The stoma is black.
C. The stoma isn't always draining any stool.
D. The patient states the website online is tender. - ANS-The answer is B. An assessment
finding of a stoma being black is not a everyday finding but represents compromised
circulation to the stoma. It calls for on the spot physician notification. The stoma need to look
pink and be vivid/moist. It is regular for a stoma to be swollen and huge after surgical
procedure (this will subside after a few months), and it's far regular for the web site to be