Clinical Nursing Skills Chapter 35: Ostomy Care questions and answers
with rationale A+ Grade 2026\2027
The nurse has inserted a catheter into a patient's urinary diversion, but only a few drops of urine have
drained. Which action should the nurse perform first to try to obtain an adequate sample? (Select all
that apply.)
1 Remove the catheter and obtain urine from the pouch.
2 Gently insert the catheter a little more.
3 Massage the patient's abdomen.
4 Have the patient turn to side.
- correct answer 2, 3, 4
Rationale: All of these actions may facilitate additional drainage through the catheter. You cannot use
urine from the pouch because it may be contaminated.
A patient has a new urostomy secondary to bladder cancer. Which patient behaviors suggest acceptance
of his change in bodily func- tion? (Select all that apply.)
1 He watches you change his pouch.
2 He asks questions about how the ostomy works.
3 He empties his pouch.
4 He says his spouse will be doing the pouch changes.
- correct answer 1, 2, 3
Rationale: Being receptive to teaching and active participa- tion in care shows the patient's acceptance
of his bodily function changes. Assigning care to his spouse is delaying or denying the return to self-care.
, The nurse is caring for a patient with a new permanent sigmoid colostomy and explaining information
about care once the patient returns home. Which statement by the patient indicates that he or she
requires further instruction on the topic?
1 "When I wash the stoma, I should just use warm water to clean the skin."
2 "If I eat a well balanced diet, the stool will be soft and formed."
3 "I'll need to look at the skin around the stoma each time I change the pouch to be sure that there is no
irritation."
4 "The stoma will stay the shape it is; so it will be easy to buy bags that fit."
- correct answer 4
Rationale: The stoma will initially be edematous. The swelling will decrease normally over 4 to 6 weeks,
and the size may change during that time.
A patient anticipating an ileostomy because of severe ulcerative colitis asks, "Will I really be able to have
a normal life after having this procedure?" What is the most appropriate reply?
1 "Let's talk about this when you're recovering from the surgery."
2 "I'm going to have a person with an ostomy visit you before the surgery."
3 "Why don't you talk with your surgeon about your concerns?"
4 "Tell me the specific questions you have about life after the
surgery."
- correct answer 4
Rationale: Assessment is the first step of the nursing process; and, by using an open-ended question,
you can determine a patient's specific concerns. Shifting responsibility to the health care pro- vider is
inappropriate, and waiting until after the surgery to address the issue only increases a patient's anxiety.
Having a person with an ostomy visit the patient before surgery may be helpful, but assessment needs
to be done first.
A patient with a urostomy notes a raw, weeping area of the skin in
an area under the skin barrier. Which action is most appropriate in this situation?
with rationale A+ Grade 2026\2027
The nurse has inserted a catheter into a patient's urinary diversion, but only a few drops of urine have
drained. Which action should the nurse perform first to try to obtain an adequate sample? (Select all
that apply.)
1 Remove the catheter and obtain urine from the pouch.
2 Gently insert the catheter a little more.
3 Massage the patient's abdomen.
4 Have the patient turn to side.
- correct answer 2, 3, 4
Rationale: All of these actions may facilitate additional drainage through the catheter. You cannot use
urine from the pouch because it may be contaminated.
A patient has a new urostomy secondary to bladder cancer. Which patient behaviors suggest acceptance
of his change in bodily func- tion? (Select all that apply.)
1 He watches you change his pouch.
2 He asks questions about how the ostomy works.
3 He empties his pouch.
4 He says his spouse will be doing the pouch changes.
- correct answer 1, 2, 3
Rationale: Being receptive to teaching and active participa- tion in care shows the patient's acceptance
of his bodily function changes. Assigning care to his spouse is delaying or denying the return to self-care.
, The nurse is caring for a patient with a new permanent sigmoid colostomy and explaining information
about care once the patient returns home. Which statement by the patient indicates that he or she
requires further instruction on the topic?
1 "When I wash the stoma, I should just use warm water to clean the skin."
2 "If I eat a well balanced diet, the stool will be soft and formed."
3 "I'll need to look at the skin around the stoma each time I change the pouch to be sure that there is no
irritation."
4 "The stoma will stay the shape it is; so it will be easy to buy bags that fit."
- correct answer 4
Rationale: The stoma will initially be edematous. The swelling will decrease normally over 4 to 6 weeks,
and the size may change during that time.
A patient anticipating an ileostomy because of severe ulcerative colitis asks, "Will I really be able to have
a normal life after having this procedure?" What is the most appropriate reply?
1 "Let's talk about this when you're recovering from the surgery."
2 "I'm going to have a person with an ostomy visit you before the surgery."
3 "Why don't you talk with your surgeon about your concerns?"
4 "Tell me the specific questions you have about life after the
surgery."
- correct answer 4
Rationale: Assessment is the first step of the nursing process; and, by using an open-ended question,
you can determine a patient's specific concerns. Shifting responsibility to the health care pro- vider is
inappropriate, and waiting until after the surgery to address the issue only increases a patient's anxiety.
Having a person with an ostomy visit the patient before surgery may be helpful, but assessment needs
to be done first.
A patient with a urostomy notes a raw, weeping area of the skin in
an area under the skin barrier. Which action is most appropriate in this situation?
