WEB WOC Wound Care and Management – Nursing Study Guide

Lab: Wound Care and Ostomy N N N N




D. Notify the health care provider. - CORRECT ANSWER-1. Which action would be the nurse's
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priority when caring for a patient with a urostomy who had no urine output for 4 hours?
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A. Change the ostomy device.
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B. Document the output.
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C. Catheterize the patient.
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D. Notify the health care provider.
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A. Apply clean gloves. - CORRECT ANSWER-1. Which action will the nurse perform first when
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preparing to change a patient's urostomy pouching system?
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A. Apply clean gloves.
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B. Drape the patient appropriately.
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C. Position absorbent padding beneath the patient.
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D. Apply sterile gloves.
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D. Protecting the skin from irritation caused by urinary drainage - CORRECT ANSWER-3. When
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pouching a patient's urostomy, which nursing action reduces the risk for injury?
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A. Collecting all urinary drainage from the urostomy
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B. Maintaining the patient's urinary elimination function
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C. Promoting the patient's autonomy with urinary elimination care
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D. Protecting the skin from irritation caused by urinary drainage
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D. Clean the skin with warm water and pat dry. - CORRECT ANSWER-4. What will the nurse do to
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protect the peristomal skin of a patient with a urostomy?
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A. Clean the skin around the stoma with soap and hot water.
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,B. Apply lotion to the skin around the stoma.
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C. Wipe the skin with alcohol swabs before applying the device.
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D. Clean the skin with warm water and pat dry.
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B. "Alert me immediately if you see any blood in the urine that has collected in the pouch." -
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CORRECT ANSWER-5. Which instruction might the nurse give to nursing assistive personnel
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(NAP) caring for a patient with a newly established urostomy?
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A. "Be sure to pat-dry the skin surrounding the stoma before applying the new pouch."
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B. "Alert me immediately if you see any blood in the urine that has collected in the pouch."
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C. "Using the stoma guide, cut the pouch opening about an eighth of an inch larger than the
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stoma."
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D. "Remember to use warm water when cleaning the stoma and the surrounding skin."
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A. Applying clean gloves - CORRECT ANSWER-1. What is the nurse's initial action when
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preparing to change a patient's colostomy pouching system?
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A. Applying clean gloves
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B. Draping the patient appropriately
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C. Emptying the colostomy
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D. Assessing the surrounding skin for signs of irritation.
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D. Giving the patient a mirror to watch the nurse provide care - CORRECT ANSWER-2. Which
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initial nursing action would best help the patient learn self-care of a colostomy pouching
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system?
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A. Giving the patient handouts on self care of a colostomy
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B. Allowing the patient to examine an ostomy device
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C. Identifying a family member who can participate in the ostomy appliance process
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D. Giving the patient a mirror to watch the nurse provide care
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, D. Protecting the skin from irritation caused by fecal drainage - CORRECT ANSWER-3. When
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pouching a patient's colostomy, which action reduces the patient's risk for injury?
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A. Measuring output when emptying the contents of the pouch
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B. Maintaining the patient's bowel elimination function
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C. Promoting the patient's autonomy with bowel elimination care
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D. Protecting the skin from irritation caused by fecal drainage
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C. Avoiding unnecessary changes of the pouching system - CORRECT ANSWER-4. When
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changing the pouching system, which routine step best minimizes irritation of the skin
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surrounding the stoma?
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A. Using adhesive remover
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B. Emptying the ostomy bag only when full
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C. Avoiding unnecessary changes of the pouching system
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D. Wearing clean gloves
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B. "Alert me immediately if you see any blood in the fecal matter in the pouch." - CORRECT
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ANSWER-5. Which instruction might the nurse give to nursing assistive personnel (NAP)
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regarding the care of a patient with a newly established colostomy?
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A. "Be sure to pat-dry the skin surrounding the stoma before applying the new pouch."
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B. "Alert me immediately if you see any blood in the fecal matter in the pouch."
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C. "Using the stoma guide, cut the pouch opening about one-eighth of an inch bigger than the
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stoma."
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D. "Remember to change your gloves after cleaning the stoma and the surrounding skin."
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C. Apply ointment to necrotic tissue in the wound while avoiding contact with surrounding skin.
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Avoiding contact with surrounding skin prevents tissue damage. Contact with surrounding skin
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needs to be avoided with an enzymatic debridement product. The middle of the wound may
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