Situation: ENTEROSTOMAL THERAPY is now considered a specialty in nursing. You are participating in the OSTOMY CARE CLASS.
1. During colostomy irrigation, the client complains of a cramping sensation with the fluid introduced. Which of the following is a CORRECT nursing action?
A. Temporarily ...
Situation: ENTEROSTOMAL THERAPY is now considered a specialty in nursing. You are participating in the
OSTOMY CARE CLASS.
1. During colostomy irrigation, the client complains of a cramping sensation with the fluid introduced.
Which of the following is a CORRECT nursing action?
A. Temporarily stop the irrigation
B. Clamp the irrigating tube
C. Pinch or kink the irrigating tube temporarily
D. Continue the irrigation correct answersB. Clamp the irrigating tube
2. When is the colostomy appliance best emptied?
A. When there is a sensation of pressure
B. When there is the sensation of taste
C. When there is the sensation of smell
D. When it is full correct answersA. When there is a sensation of pressure
3. The client asked the nurse when the best time to perform irrigation is. The nurse would answer:
A. Early morning, before meals, upon arising
B. Early morning, before meals
C. Early morning
D. Early morning, After meals correct answersD. Early morning, After meals
4. The nurse is teaching a client how to irrigate his stoma. Which action indicates that the client needs
more teaching?
,A. Hanging the irrigation bag 24" to 36" (60 to 90 cm) above the stoma
B. Filling the irrigation bag with 500 to 1,000 ml of lukewarm water
C. Stopping irrigation for cramps and clamping the tubing until cramps pass
D. Washing hands with soap and water when finished correct answersD. Washing hands with soap and
water when finished
5. The physician orders a stool culture to help diagnose a client with prolonged diarrhea. The nurse who
obtains the stool specimen from the colostomy stoma should:
A. take the specimen to the laboratory immediately.
B. collect the specimen in a clean container.
C. collect the specimen in a sterile container.
D. perform a midstream clean catch collection. correct answersC. collect the specimen in a sterile
container.
6. You plan to teach Fermin how to irrigate the colostomy when:
A. The perineal wound heals And Fermin can sit comfortably on the commode
B. Fermin can lie on the side comfortably, about the 3rd postoperative day
C. The abdominal incision is closed and contamination is no longer a danger
D. The stools starts to become formed, around the 7th postoperative day correct answersD. The stools
starts to become formed, around the 7th postoperative day
7. When preparing to teach Fermin how to irrigate colostomy, you should plan to do the procedure:
A. When Fermin would have normal bowel movement
B. At least 2 hours before visiting hours
C. Prior to breakfast and morning care
, D. After Fermin accepts alteration in body image correct answersA. When Fermin would have normal
bowel movement
8. When observing a return demonstration of a colostomy irrigation, you know that more teaching is
required if Fermin:
A. Lubricates the tip of the catheter prior to inserting into the stoma
B. Hangs the irrigating bag on the bathroom door cloth hook during fluid insertion
C. Discontinues the insertion of fluid after 500 ml of fluid has been instilled
D. Clamps of the flow of fluid when feeling uncomfortable correct answersB. Hangs the irrigating bag on
the bathroom door cloth hook during fluid insertion
9. You are aware that teaching about colostomy care is understood when Fermin states, "I will contact
my physician and report:
A. If I have any difficulty inserting the irrigating tub into the stoma."
B. If I notice a loss of sensation to touch in the stoma tissue."
C. The expulsion of flatus while the irrigating fluid is running out."
D. When mucus is passed from the stoma between the irrigations." correct answersA. If I have any
difficulty inserting the irrigating tub into the stoma."
10. You would know after teaching Fermin that dietary instruction for him is effective when he states, "It
is important that I eat:
A. Soft food that is easily digested and absorbed by my large intestines."
B. Bland food so that my intestines do not become irritated."
C. Food low in fiber so that there are fewer stools."
D. Everything that I ate before the operation, while avoiding foods that cause gas." correct answersD.
Everything that I ate before the operation, while avoiding foods that cause gas."
SITUATION: A Client was rushed to the emergency room and you are his attending nurse. You are
performing a vital sign assessment.
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