LAB: WOUND CARE AND OSTOMY
QUESTIONS AND ANSWERS WITH
COMPLETE SOLUTIONS 100%
CORRECT RATED A+
Question 1: Priority Action for Absence of Output
Which action would be the nurse's priority when caring for a patient with a
urostomy who has had no urine output for 4 hours?
A. Change the ostomy device.
B. Document the output.
C. Catheterize the patient.
D. Notify the health care provider.
✔✔ Answer: D. Notify the health care provider.
Clinical Rationale: A urostomy (such as an ileal conduit) continuously drains
urine from the kidneys; unlike the urinary bladder, it does not store urine. An
absence of urine output for 4 hours is an acute medical emergency indicating
potential ureteral obstruction, acute kidney injury, or a dislodged stent. The nurse
must immediately notify the healthcare provider to evaluate for renal dysfunction
or mechanical obstruction.
Question 2: Initial Action for Changing a Pouching System
Which action will the nurse perform first when preparing to change a
patient's urostomy pouching system?
A. Apply clean gloves.
B. Drape the patient appropriately.
C. Position absorbent padding beneath the patient.
D. Apply sterile gloves.
✔✔ Answer: A. Apply clean gloves.
,Clinical Rationale: Standard infection control protocols dictate that personal
protective equipment (PPE)—specifically clean gloves—must be applied before
touching bodily fluid drainage or removing the old, contaminated pouching
system. Stoma pouch changes are a clean technique (not sterile), so clean gloves
are appropriate.
Question 3: Primary Goal for Reducing Injury During Pouching
When pouching a patient's urostomy, which nursing action directly reduces
the risk for patient injury?
A. Collecting all urinary drainage from the urostomy
B. Maintaining the patient's urinary elimination function
C. Promoting the patient's autonomy with urinary elimination care
D. Protecting the skin from irritation caused by urinary drainage
✔✔ Answer: D. Protecting the skin from irritation caused by urinary
drainage
Clinical Rationale: Peristomal skin protection is the primary goal to prevent tissue
damage and skin failure. Continuous exposure to acidic, moisture-rich urinary
drainage causes severe Maceration and Moisture-Associated Skin Damage
(MASD). Ensuring a proper skin barrier seal directly prevents peristomal chemical
dermatitis and skin breakdown.
D. Clean the skin with warm water and pat dry. -ANSWER ✔✔4. What will the
nurse do to protect the peristomal skin of a patient with a urostomy?
A. Clean the skin around the stoma with soap and hot water.
B. Apply lotion to the skin around the stoma.
C. Wipe the skin with alcohol swabs before applying the device.
D. Clean the skin with warm water and pat dry.
, B. "Alert me immediately if you see any blood in the urine that has collected in the
pouch." -ANSWER ✔✔5. Which instruction might the nurse give to nursing
assistive personnel (NAP) caring for a patient with a newly established urostomy?
A. "Be sure to pat-dry the skin surrounding the stoma before applying the new
pouch."
B. "Alert me immediately if you see any blood in the urine that has collected in the
pouch."
C. "Using the stoma guide, cut the pouch opening about an eighth of an inch larger
than the stoma."
D. "Remember to use warm water when cleaning the stoma and the surrounding
skin."
A. Applying clean gloves -ANSWER ✔✔1. What is the nurse's initial action when
preparing to change a patient's colostomy pouching system?
A. Applying clean gloves
B. Draping the patient appropriately
C. Emptying the colostomy
D. Assessing the surrounding skin for signs of irritation.
D. Giving the patient a mirror to watch the nurse provide care -ANSWER ✔✔2.
Which initial nursing action would best help the patient learn self-care of a
colostomy pouching system?
A. Giving the patient handouts on self care of a colostomy
B. Allowing the patient to examine an ostomy device
C. Identifying a family member who can participate in the ostomy appliance
process
D. Giving the patient a mirror to watch the nurse provide care
QUESTIONS AND ANSWERS WITH
COMPLETE SOLUTIONS 100%
CORRECT RATED A+
Question 1: Priority Action for Absence of Output
Which action would be the nurse's priority when caring for a patient with a
urostomy who has had no urine output for 4 hours?
A. Change the ostomy device.
B. Document the output.
C. Catheterize the patient.
D. Notify the health care provider.
✔✔ Answer: D. Notify the health care provider.
Clinical Rationale: A urostomy (such as an ileal conduit) continuously drains
urine from the kidneys; unlike the urinary bladder, it does not store urine. An
absence of urine output for 4 hours is an acute medical emergency indicating
potential ureteral obstruction, acute kidney injury, or a dislodged stent. The nurse
must immediately notify the healthcare provider to evaluate for renal dysfunction
or mechanical obstruction.
Question 2: Initial Action for Changing a Pouching System
Which action will the nurse perform first when preparing to change a
patient's urostomy pouching system?
A. Apply clean gloves.
B. Drape the patient appropriately.
C. Position absorbent padding beneath the patient.
D. Apply sterile gloves.
✔✔ Answer: A. Apply clean gloves.
,Clinical Rationale: Standard infection control protocols dictate that personal
protective equipment (PPE)—specifically clean gloves—must be applied before
touching bodily fluid drainage or removing the old, contaminated pouching
system. Stoma pouch changes are a clean technique (not sterile), so clean gloves
are appropriate.
Question 3: Primary Goal for Reducing Injury During Pouching
When pouching a patient's urostomy, which nursing action directly reduces
the risk for patient injury?
A. Collecting all urinary drainage from the urostomy
B. Maintaining the patient's urinary elimination function
C. Promoting the patient's autonomy with urinary elimination care
D. Protecting the skin from irritation caused by urinary drainage
✔✔ Answer: D. Protecting the skin from irritation caused by urinary
drainage
Clinical Rationale: Peristomal skin protection is the primary goal to prevent tissue
damage and skin failure. Continuous exposure to acidic, moisture-rich urinary
drainage causes severe Maceration and Moisture-Associated Skin Damage
(MASD). Ensuring a proper skin barrier seal directly prevents peristomal chemical
dermatitis and skin breakdown.
D. Clean the skin with warm water and pat dry. -ANSWER ✔✔4. What will the
nurse do to protect the peristomal skin of a patient with a urostomy?
A. Clean the skin around the stoma with soap and hot water.
B. Apply lotion to the skin around the stoma.
C. Wipe the skin with alcohol swabs before applying the device.
D. Clean the skin with warm water and pat dry.
, B. "Alert me immediately if you see any blood in the urine that has collected in the
pouch." -ANSWER ✔✔5. Which instruction might the nurse give to nursing
assistive personnel (NAP) caring for a patient with a newly established urostomy?
A. "Be sure to pat-dry the skin surrounding the stoma before applying the new
pouch."
B. "Alert me immediately if you see any blood in the urine that has collected in the
pouch."
C. "Using the stoma guide, cut the pouch opening about an eighth of an inch larger
than the stoma."
D. "Remember to use warm water when cleaning the stoma and the surrounding
skin."
A. Applying clean gloves -ANSWER ✔✔1. What is the nurse's initial action when
preparing to change a patient's colostomy pouching system?
A. Applying clean gloves
B. Draping the patient appropriately
C. Emptying the colostomy
D. Assessing the surrounding skin for signs of irritation.
D. Giving the patient a mirror to watch the nurse provide care -ANSWER ✔✔2.
Which initial nursing action would best help the patient learn self-care of a
colostomy pouching system?
A. Giving the patient handouts on self care of a colostomy
B. Allowing the patient to examine an ostomy device
C. Identifying a family member who can participate in the ostomy appliance
process
D. Giving the patient a mirror to watch the nurse provide care
