BSN 206 - ISB - Bowel Elimination/Ostomy Care
Lesson 4 Post Test With Complete Solutions
The nurse is pouching an enterostomy. Assuming all other steps are performed correctly,
which of the following steps is incorrect?
The nurse observes the skin barrier for leakage and length of time in place.
The nurse cleans the peristomal skin vigorously with warm tap water, selects a pouch,
removes the backing and cuts the opening on the pouch to one-quarter inch larger than the
stoma.
The nurse applies the pouch over the stoma pressing firmly around stoma and outside edges,
and has the patient hold hand over pouch to apply heat to secure seal.
The nurse removes drape from patient, removes gloves, and performs hand hygiene. The
nurse documents the procedure. - ANSWER The nurse cleans the peristomal skin vigorously
with warm tap water, selects a pouch, removes the backing and cuts the opening on the
pouch to one-quarter inch larger than the stoma.
When is the best time to change the skin barrier pouch?
(Select all that apply.)
After breakfast.
After lunch.
Lesson 4 Post Test With Complete Solutions
The nurse is pouching an enterostomy. Assuming all other steps are performed correctly,
which of the following steps is incorrect?
The nurse observes the skin barrier for leakage and length of time in place.
The nurse cleans the peristomal skin vigorously with warm tap water, selects a pouch,
removes the backing and cuts the opening on the pouch to one-quarter inch larger than the
stoma.
The nurse applies the pouch over the stoma pressing firmly around stoma and outside edges,
and has the patient hold hand over pouch to apply heat to secure seal.
The nurse removes drape from patient, removes gloves, and performs hand hygiene. The
nurse documents the procedure. - ANSWER The nurse cleans the peristomal skin vigorously
with warm tap water, selects a pouch, removes the backing and cuts the opening on the
pouch to one-quarter inch larger than the stoma.
When is the best time to change the skin barrier pouch?
(Select all that apply.)
After breakfast.
After lunch.
