Patient Care Rounds: Bowel Diversion Summary |
Nursing Study Guide PDF
Exam Coverage Summary
This examination covers all aspects of bowel diversion care including ostomy types (colostomy and
ileostomy), surgical indications, pre-operative and post-operative management, stoma assessment,
complications, dietary considerations, fluid and electrolyte balance, patient education, psychosocial
support, and nursing interventions for patients with bowel diversions. The content encompasses
anatomical considerations, ostomy location and corresponding stool characteristics, developmental
considerations across the lifespan, assessment techniques, and documentation requirements for
comprehensive patient care.
1. A nurse is assessing a client's new stoma on the second postoperative day and notes a beefy red, moist
appearance with slight edema. What is the most appropriate nursing action?
A) Notify the healthcare provider immediately
B) Apply a cold compress to reduce edema
C) Document the findings as normal and continue monitoring
D) Apply a barrier cream to prevent skin breakdown
C) Document the findings as normal and continue monitoring A healthy stoma appears beefy red, moist,
and may have slight edema for several weeks postoperatively; this is a normal finding that requires
ongoing monitoring and documentation
2. A client with an ileostomy is concerned about the frequent liquid drainage from their stoma. Which
nursing response is most accurate regarding this concern?
A) "This indicates you need to increase your fiber intake significantly"
B) "Liquid drainage is expected with an ileostomy because the small intestine does not absorb water"
C) "You should restrict all fluids to decrease the drainage amount"
D) "This means your ostomy is not functioning properly and needs revision"
B) "Liquid drainage is expected with an ileostomy because the small intestine does not absorb water" The
ileum does not reabsorb water like the colon does, resulting in continuous liquid effluent that contains
digestive enzymes and requires diligent skin protection
,3. During a colonoscopy, a physician discovers abnormal growths in the large intestine that require
biopsy. What are these abnormal findings correctly termed?
A) Diverticula
B) Polyps
C) Ulcerations
D) Strictures
B) Polyps Polyps are abnormal growths found in the large intestine and rectum that require biopsy to test
for malignancy, as they can be precursors to colorectal cancer
4. A nurse is teaching a client with a new colostomy about dietary management. Which food choice
indicates the client understands the initial dietary restrictions?
A) Fresh strawberries with seeds
B) Whole grain bread
C) Clear chicken broth
D) Raw vegetable salad
C) Clear chicken broth A low-residue diet with strained foods and clear liquids is recommended initially
to minimize stool output and allow the bowel to heal; fibrous foods and seeds are restricted early in
recovery
5. A client with a sigmoid colostomy asks why they have formed stool while other ostomy patients have
liquid drainage. What is the nurse's best response?
A) "Your medication is causing your stool to be more formed"
B) "The location of your colostomy determines the consistency of your stool"
C) "You are not drinking enough fluids"
D) "This means your ostomy is healing properly"
B) "The location of your colostomy determines the consistency of your stool" Sigmoid colostomies
produce formed stool because the stool has passed through most of the colon where water reabsorption
occurs, allowing for more formed output
6. A nurse is caring for a postoperative client with an ileostomy. Which assessment finding requires
immediate notification of the healthcare provider?
A) Stoma appears pink and moist
B) Stoma output is 500 mL in 24 hours
C) Stoma appears dark purple in color
D) Peristomal skin has slight redness
C) Stoma appears dark purple in color A dark purple, black, or white stoma indicates ischemia and
,compromised blood supply, which is a medical emergency requiring immediate notification of the
healthcare provider
7. A client with an ostomy is preparing for discharge and states, "I will never be able to wear my regular
clothes again." What is the nurse's most therapeutic response?
A) "You will need to buy new clothes that are larger"
B) "Many people with ostomies wear regular clothing with a pouch cover"
C) "You should wear loose-fitting clothes only"
D) "Maybe you should consider a different ostomy procedure"
B) "Many people with ostomies wear regular clothing with a pouch cover" Clients can wear regular
clothing with appropriate pouch covers, and it is important to provide accurate information and
emotional support to address body image concerns
8. A nurse is changing an ostomy pouch and notes the skin around the stoma appears red and irritated.
Which action should the nurse take?
A) Apply a skin barrier powder and sealant
B) Cut the wafer larger than the stoma
C) Leave the skin exposed to air for healing
D) Apply an alcohol-based cleanser
A) Apply a skin barrier powder and sealant Peristomal skin irritation requires application of skin barrier
products to protect the skin from corrosive enzymes in the effluent while allowing healing to occur
9. A client with Crohn's disease is scheduled for an ileostomy procedure. The client asks what Crohn's
disease is. What is the nurse's best response?
A) "A condition where abnormal growths develop in the large intestine"
B) "An autoimmune disorder affecting the entire digestive tract"
C) "An inflammatory bowel disease causing severe diarrhea and abdominal pain"
D) "A condition that affects only the rectum and anus"
C) "An inflammatory bowel disease causing severe diarrhea and abdominal pain" Crohn's disease is an
inflammatory bowel disease that causes severe diarrhea, abdominal pain, fatigue, and weight loss; it is a
chronic condition with potential complications
10. A client has an ostomy located in the right lower quadrant of the abdomen. Which type of stool
consistency should the nurse expect?
A) Formed stool
B) Liquid stool
, C) Mushy, semi-formed stool
D) Hard, dry stool
B) Liquid stool An ileostomy located in the right lower quadrant produces liquid stool because the
effluent comes directly from the small intestine where minimal water reabsorption has occurred
11. A nurse is assessing a client's stoma three weeks after surgery. The stoma appears smaller than
immediately after surgery. What is the most appropriate nursing action?
A) Notify the healthcare provider immediately
B) Reassure the client this is a normal finding
C) Apply pressure to the stoma to prevent further shrinkage
D) Increase the client's fluid intake
B) Reassure the client this is a normal finding Stomas rechecked at 3 weeks postoperatively will appear
smaller as edema subsides; permanent size is achieved at approximately 6 months post-surgery
12. A client with an ileostomy is experiencing frequent episodes of dehydration. Which intervention
should the nurse prioritize?
A) Restrict all fluid intake to decrease output
B) Encourage sports drinks and increase fluid intake to 2-3 L/day
C) Administer anti-diarrheal medications
D) Decrease dietary fiber consumption
B) Encourage sports drinks and increase fluid intake to 2-3 L/day Clients with ileostomies are at high risk
for dehydration and electrolyte imbalance due to continuous liquid output; sports drinks help replace
electrolytes while maintaining hydration
13. During a nursing assessment, the nurse auscultates the abdomen and hears no bowel sounds after 5
minutes of listening. What is the most appropriate nursing action?
A) Document the findings as normal
B) Continue listening for an additional 2 minutes
C) Notify the healthcare provider
D) Palpate the abdomen to stimulate bowel sounds
C) Notify the healthcare provider Absent bowel sounds, defined as no sounds heard within 3-5 minutes,
may indicate a paralytic ileus or other complication requiring healthcare provider notification
14. A nurse is educating a client about changing an ostomy pouching system. Which statement indicates
the client needs further teaching?
A) "I will clean the skin with warm water and dry thoroughly"
Nursing Study Guide PDF
Exam Coverage Summary
This examination covers all aspects of bowel diversion care including ostomy types (colostomy and
ileostomy), surgical indications, pre-operative and post-operative management, stoma assessment,
complications, dietary considerations, fluid and electrolyte balance, patient education, psychosocial
support, and nursing interventions for patients with bowel diversions. The content encompasses
anatomical considerations, ostomy location and corresponding stool characteristics, developmental
considerations across the lifespan, assessment techniques, and documentation requirements for
comprehensive patient care.
1. A nurse is assessing a client's new stoma on the second postoperative day and notes a beefy red, moist
appearance with slight edema. What is the most appropriate nursing action?
A) Notify the healthcare provider immediately
B) Apply a cold compress to reduce edema
C) Document the findings as normal and continue monitoring
D) Apply a barrier cream to prevent skin breakdown
C) Document the findings as normal and continue monitoring A healthy stoma appears beefy red, moist,
and may have slight edema for several weeks postoperatively; this is a normal finding that requires
ongoing monitoring and documentation
2. A client with an ileostomy is concerned about the frequent liquid drainage from their stoma. Which
nursing response is most accurate regarding this concern?
A) "This indicates you need to increase your fiber intake significantly"
B) "Liquid drainage is expected with an ileostomy because the small intestine does not absorb water"
C) "You should restrict all fluids to decrease the drainage amount"
D) "This means your ostomy is not functioning properly and needs revision"
B) "Liquid drainage is expected with an ileostomy because the small intestine does not absorb water" The
ileum does not reabsorb water like the colon does, resulting in continuous liquid effluent that contains
digestive enzymes and requires diligent skin protection
,3. During a colonoscopy, a physician discovers abnormal growths in the large intestine that require
biopsy. What are these abnormal findings correctly termed?
A) Diverticula
B) Polyps
C) Ulcerations
D) Strictures
B) Polyps Polyps are abnormal growths found in the large intestine and rectum that require biopsy to test
for malignancy, as they can be precursors to colorectal cancer
4. A nurse is teaching a client with a new colostomy about dietary management. Which food choice
indicates the client understands the initial dietary restrictions?
A) Fresh strawberries with seeds
B) Whole grain bread
C) Clear chicken broth
D) Raw vegetable salad
C) Clear chicken broth A low-residue diet with strained foods and clear liquids is recommended initially
to minimize stool output and allow the bowel to heal; fibrous foods and seeds are restricted early in
recovery
5. A client with a sigmoid colostomy asks why they have formed stool while other ostomy patients have
liquid drainage. What is the nurse's best response?
A) "Your medication is causing your stool to be more formed"
B) "The location of your colostomy determines the consistency of your stool"
C) "You are not drinking enough fluids"
D) "This means your ostomy is healing properly"
B) "The location of your colostomy determines the consistency of your stool" Sigmoid colostomies
produce formed stool because the stool has passed through most of the colon where water reabsorption
occurs, allowing for more formed output
6. A nurse is caring for a postoperative client with an ileostomy. Which assessment finding requires
immediate notification of the healthcare provider?
A) Stoma appears pink and moist
B) Stoma output is 500 mL in 24 hours
C) Stoma appears dark purple in color
D) Peristomal skin has slight redness
C) Stoma appears dark purple in color A dark purple, black, or white stoma indicates ischemia and
,compromised blood supply, which is a medical emergency requiring immediate notification of the
healthcare provider
7. A client with an ostomy is preparing for discharge and states, "I will never be able to wear my regular
clothes again." What is the nurse's most therapeutic response?
A) "You will need to buy new clothes that are larger"
B) "Many people with ostomies wear regular clothing with a pouch cover"
C) "You should wear loose-fitting clothes only"
D) "Maybe you should consider a different ostomy procedure"
B) "Many people with ostomies wear regular clothing with a pouch cover" Clients can wear regular
clothing with appropriate pouch covers, and it is important to provide accurate information and
emotional support to address body image concerns
8. A nurse is changing an ostomy pouch and notes the skin around the stoma appears red and irritated.
Which action should the nurse take?
A) Apply a skin barrier powder and sealant
B) Cut the wafer larger than the stoma
C) Leave the skin exposed to air for healing
D) Apply an alcohol-based cleanser
A) Apply a skin barrier powder and sealant Peristomal skin irritation requires application of skin barrier
products to protect the skin from corrosive enzymes in the effluent while allowing healing to occur
9. A client with Crohn's disease is scheduled for an ileostomy procedure. The client asks what Crohn's
disease is. What is the nurse's best response?
A) "A condition where abnormal growths develop in the large intestine"
B) "An autoimmune disorder affecting the entire digestive tract"
C) "An inflammatory bowel disease causing severe diarrhea and abdominal pain"
D) "A condition that affects only the rectum and anus"
C) "An inflammatory bowel disease causing severe diarrhea and abdominal pain" Crohn's disease is an
inflammatory bowel disease that causes severe diarrhea, abdominal pain, fatigue, and weight loss; it is a
chronic condition with potential complications
10. A client has an ostomy located in the right lower quadrant of the abdomen. Which type of stool
consistency should the nurse expect?
A) Formed stool
B) Liquid stool
, C) Mushy, semi-formed stool
D) Hard, dry stool
B) Liquid stool An ileostomy located in the right lower quadrant produces liquid stool because the
effluent comes directly from the small intestine where minimal water reabsorption has occurred
11. A nurse is assessing a client's stoma three weeks after surgery. The stoma appears smaller than
immediately after surgery. What is the most appropriate nursing action?
A) Notify the healthcare provider immediately
B) Reassure the client this is a normal finding
C) Apply pressure to the stoma to prevent further shrinkage
D) Increase the client's fluid intake
B) Reassure the client this is a normal finding Stomas rechecked at 3 weeks postoperatively will appear
smaller as edema subsides; permanent size is achieved at approximately 6 months post-surgery
12. A client with an ileostomy is experiencing frequent episodes of dehydration. Which intervention
should the nurse prioritize?
A) Restrict all fluid intake to decrease output
B) Encourage sports drinks and increase fluid intake to 2-3 L/day
C) Administer anti-diarrheal medications
D) Decrease dietary fiber consumption
B) Encourage sports drinks and increase fluid intake to 2-3 L/day Clients with ileostomies are at high risk
for dehydration and electrolyte imbalance due to continuous liquid output; sports drinks help replace
electrolytes while maintaining hydration
13. During a nursing assessment, the nurse auscultates the abdomen and hears no bowel sounds after 5
minutes of listening. What is the most appropriate nursing action?
A) Document the findings as normal
B) Continue listening for an additional 2 minutes
C) Notify the healthcare provider
D) Palpate the abdomen to stimulate bowel sounds
C) Notify the healthcare provider Absent bowel sounds, defined as no sounds heard within 3-5 minutes,
may indicate a paralytic ileus or other complication requiring healthcare provider notification
14. A nurse is educating a client about changing an ostomy pouching system. Which statement indicates
the client needs further teaching?
A) "I will clean the skin with warm water and dry thoroughly"
