1.
Arthur, a 46-year-old artist, has recently had an abdominoperineal resection and colostomy. Mr. Cruz accuses the nurse of being uncomfortable during a dressing change because his “wound looks terrible.” The nurse recognizes that the client is using the defense mechanism known as:
Correct Answer
D. Projection
Explanation
Projection is a defense mechanism where an individual attributes their own unacceptable thoughts, feelings, or characteristics onto someone else. In this case, Mr. Cruz is accusing the nurse of being uncomfortable during the dressing change because he himself feels uncomfortable and insecure about the appearance of his wound. He is projecting his own negative feelings onto the nurse, which is a common behavior seen in projection.
2.
When preparing to teach a client with colostomy how to irrigate his colostomy, the nurse should plan to perform the procedure:
Correct Answer
A. When the client would have normally had a bowel movement.
Explanation
The correct answer is when the client would have normally had a bowel movement. This is because irrigating the colostomy at the same time the client would have had a bowel movement helps to establish a regular routine and promotes better control over bowel elimination. It also helps to prevent accidents and allows the client to plan their activities accordingly.
3.
When observing an ostomate do a return demonstration of the colostomy irrigation, the nurse notes that he needs more teaching if he:
Correct Answer
C. Hangs the bag on a clothes hook on the bathroom door during fluid insertion
Explanation
Hanging the bag on a clothes hook on the bathroom door during fluid insertion is incorrect because it can cause the bag to pull on the stoma, potentially causing discomfort or injury. It is important to ensure that the bag is properly supported and positioned during the procedure to prevent any complications.
4.
When doing colostomy irrigation at home, a client with colostomy should be instructed to report to his physician :
Correct Answer
B. Difficulty in inserting the irrigating tube
Explanation
When doing colostomy irrigation at home, it is important for the client to be able to insert the irrigating tube without difficulty. Difficulty in inserting the tube may indicate a blockage or obstruction in the stoma, which could lead to complications if not addressed. It is important for the client to report this to their physician so that appropriate measures can be taken to ensure the success and safety of the colostomy irrigation procedure.
5.
A client with colostomy refuses to allow his wife to see the incision or stoma and ignores most of his dietary instructions. The nurse on assessing this data, can assume that the client is experiencing:
Correct Answer
B. A difficult time accepting reality and is in a state of denial.
Explanation
The client's refusal to allow his wife to see the incision or stoma and ignoring dietary instructions suggests that he is having a difficult time accepting the reality of his altered body image. This behavior can be seen as a defense mechanism known as denial, where the individual refuses to acknowledge or accept a painful or distressing reality.
6.
The nurse would know that dietary teaching had been effective for a client with colostomy when he states that he will eat:
Correct Answer
B. Everything he ate before the operation but will avoid those foods that cause gas
Explanation
The correct answer is "Everything he ate before the operation but will avoid those foods that cause gas." This answer indicates that the client understands the dietary teaching and will continue to eat a balanced diet but will avoid foods that may cause gas, which is important for a client with a colostomy to prevent discomfort and potential complications.
7.
The nurse is caring for a male client postoperatively following creation of a colostomy. Which nursing diagnosis should the nurse include in the plan of care?
Correct Answer
B. Body image, disturbed
Explanation
After undergoing a colostomy surgery, the client may experience a disturbance in body image due to the presence of the colostomy bag and the changes in their appearance and bodily functions. This can lead to feelings of embarrassment, self-consciousness, and a negative impact on self-esteem. Including the nursing diagnosis of "Body image, disturbed" in the plan of care will allow the nurse to address these psychological and emotional concerns, provide support, and help the client adapt to their new body image.
8.
The nurse is performing a colostomy irrigation on a male client. During the irrigation, the client begins to complain of abdominal cramps. What is the appropriate nursing action?
Correct Answer
B. Stop the irrigation temporarily
Explanation
If the client begins to complain of abdominal cramps during a colostomy irrigation, the appropriate nursing action is to stop the irrigation temporarily. Abdominal cramps could be a sign of discomfort or potential complications, and stopping the irrigation allows the nurse to assess the client's condition and address any issues before continuing the procedure. It is important to prioritize the client's comfort and well-being.
9.
The nurse is teaching a client how to perform colostomy irrigation. To enhance the effectiveness of the irrigation and fecal returns, what measure should the nurse instruct the client to do?
Correct Answer
A. Increase fluid intake
Explanation
Increasing fluid intake can help enhance the effectiveness of colostomy irrigation and improve fecal returns. Adequate hydration can soften the stool, making it easier to pass through the colostomy. It can also help prevent constipation and maintain regular bowel movements. By increasing fluid intake, the client can ensure that there is enough fluid in their system to facilitate the irrigation process and promote a successful outcome.
10.
The nurse is caring for a client with a colostomy. The client tells the nurse that he makes small pin holes in the drainage bag to help relieve gas. The nurse should teach him that this action:
Correct Answer
A. Destroys the odor-proof seal
Explanation
Making small pin holes in the drainage bag will indeed destroy the odor-proof seal. The odor-proof seal is important in preventing any unpleasant smells from escaping the bag. By creating holes, the seal is compromised, and the bag will no longer be able to effectively contain and mask any odors. Therefore, this action is not recommended for relieving gas in a colostomy system.
11.
A Client is scheduled to have a descending colostomy. He’s very anxious and has many questions regarding the surgical procedure, care of stoma, and lifestyle changes. It would be most appropriate for the nurse to make a referral to which member of the health care team?
Correct Answer
D. Enterostomal nurse therapist
Explanation
The enterostomal nurse therapist would be the most appropriate member of the healthcare team to refer the client to. This specialized nurse has expertise in caring for patients with stomas, including providing education on surgical procedures, stoma care, and lifestyle changes. They can address the client's anxiety and answer their questions, providing the necessary support and guidance throughout the process.
12.
SITUATION: Michiel, A male patient diagnosed with colon cancer was newly put in colostomy.
Michiel shows the BEST adaptation with the new colostomy if he shows which of the following?
Correct Answer
B. Participate with the nurse in his daily ostomy care
Explanation
Actual participation conveys positive acceptance and adjustment to the altered body image. Although looking at the ostomy site also conveys acceptance and adjustment, Participating with the nurse to his daily ostomy care is the BEST adaptation a client can make during the first few days after colostomy creation.
13.
The nurse plans to teach Michiel about colostomy irrigation. As the nurse prepares the materials needed, which of the following item indicates that the nurse needs further instruction?
Correct Answer
A. Plain NSS / Normal Saline
Explanation
The nurse needs further instruction if they are preparing Plain NSS / Normal Saline for colostomy irrigation. Colostomy irrigation is typically performed using tap water, not saline solution. Saline solution can be irritating to the stoma and may cause discomfort or complications. Therefore, the nurse should be educated on the appropriate materials to use for colostomy irrigation.
14.
The nurse should insert the colostomy tube for irrigation at approximately
Correct Answer
B. 3-4 inches
Explanation
15.
The maximum height of irrigation solution for colostomy is
Correct Answer(s)
B. 12 inches
C. 18 inches
Explanation
The maximum height of irrigation solution for colostomy is 12 inches or 18 inches. This is because irrigating the colostomy with a solution that is too high can cause discomfort, pain, and potential damage to the stoma. By keeping the height of the irrigation solution within the range of 12-18 inches, it allows for a gentle flow of the solution into the stoma without causing any harm.
16.
Which of the following behavior of the client indicates the best initial step in learning to care for his colostomy?
Correct Answer
C. Agrees to look at the colostomy
Explanation
The client agreeing to look at the colostomy indicates the best initial step in learning to care for it. This shows a willingness to actively participate in their own care and take responsibility for their colostomy. By looking at the colostomy, the client can begin to familiarize themselves with its appearance and understand the importance of proper care. This step is crucial in empowering the client to eventually perform colostomy care independently.
17.
While irrigating the client’s colostomy, Michiel suddenly complains of severe cramping. Initially, the nurse would
Correct Answer
A. Stop the irrigation by clamping the tube
Explanation
If Michiel suddenly complains of severe cramping while irrigating the client's colostomy, the nurse should stop the irrigation by clamping the tube. Severe cramping could indicate a problem or complication, and continuing the irrigation could worsen the condition. By stopping the irrigation, the nurse can prevent further discomfort or harm to the client and assess the situation to determine the cause of the cramping.
18.
The next day, the nurse will assess Michiel’s stoma. The nurse noticed that a prolapsed stoma is evident if she sees which of the following?
Correct Answer
D. Protruding stoma with swollen appearance
Explanation
A prolapsed stoma refers to a condition where the stoma protrudes or extends beyond its normal position. It is often accompanied by swelling, which gives it a swollen appearance. Therefore, the correct answer is "Protruding stoma with swollen appearance." This option indicates that the nurse should look for a stoma that is sticking out and appears swollen when assessing Michiel's stoma the next day.
19.
Michiel asked the nurse, what foods will help lessen the odor of his colostomy. The nurse best response would be
Correct Answer
C. Eat beet greens and parsley
Explanation
The nurse's best response would be to suggest eating beet greens and parsley. Both of these foods have been known to help reduce the odor associated with colostomy.
20.
The nurse will start to teach Michiel about the techniques for colostomy irrigation. Which of the following should be included in the nurse’s teaching plan?
Correct Answer
B. Suspend the irrigant 45 cm above the stoma
Explanation
The nurse should include in the teaching plan to suspend the irrigant 45 cm above the stoma. This is important because the height at which the irrigant is suspended affects the flow rate and pressure of the irrigation solution. Suspend the irrigant too high, and the flow rate may be too fast and cause discomfort or injury. Suspend it too low, and the flow rate may be too slow and ineffective. Therefore, suspending the irrigant at a specific height ensures optimal flow rate and pressure for effective colostomy irrigation.
21.
The nurse knew that the normal color of Michiel’s stoma should be
Correct Answer
A. Brick Red
Explanation
The nurse knew that the normal color of Michiel's stoma should be brick red. This indicates that the stoma is healthy and functioning properly. Gray, blue, or pale pink color of the stoma could be a sign of inadequate blood supply or other complications. Therefore, the nurse identified the correct color as brick red to ensure Michiel's stoma is in good condition.
22.
Nurse Michelle should know that the drainage is normal 4 days after a sigmoid colostomy when the stool is:
Correct Answer
C. Loose, bloody
Explanation
Nurse Michelle should know that the drainage is normal 4 days after a sigmoid colostomy when the stool is loose and bloody. This is because after a sigmoid colostomy, it is expected for the stool consistency to be loose and the presence of blood is also normal. It indicates that the surgical site is healing properly and there is no blockage or infection. It is important for the nurse to be aware of what is considered normal post-operative drainage to provide appropriate care and monitor the patient's condition effectively.
23.
The nurse teaches the patient whose surgery will result in a sigmoid colostomy that the feces expelled through the colostomy will be
Correct Answer
A. Solid.
Explanation
24.
When irrigating a colostomy, the nurse lubricates the catheter and gently inserts it into the stoma no more than _______ inches
Correct Answer
A. 3”
Explanation
When irrigating a colostomy, the nurse should lubricate the catheter and gently insert it into the stoma no more than 3 inches. This length ensures that the catheter reaches the appropriate area without causing any discomfort or damage to the patient. Inserting the catheter too far can potentially cause injury or irritation to the stoma or surrounding tissues. Therefore, it is important for the nurse to be cautious and follow the recommended insertion length of 3 inches.
25.
Discharge instructions for a patient who has been operated on for colorectal cancer include irrigating the colostomy. The nurse knows her teaching is effective when the patient states he’ll contact the doctor if:
Correct Answer
B. He has difficulty inserting the irrigation tube into the stoma
Explanation
The correct answer is "He has difficulty inserting the irrigation tube into the stoma." This is the correct answer because if the patient is unable to properly insert the irrigation tube into the stoma, it may indicate a blockage or other issue that needs to be addressed by the doctor. This could prevent the proper irrigation of the colostomy and potentially lead to complications.
26.
The first day after, surgery the nurse finds no measurable fecal drainage from a patient’s colostomy stoma. What is the most appropriate nursing intervention?
Correct Answer
D. Continue the current plan of care.
Explanation
It is normal for a patient to have no measurable fecal drainage from a colostomy stoma on the first day after surgery. The stoma may take some time to start functioning properly. Therefore, the most appropriate nursing intervention is to continue with the current plan of care and monitor the patient for any signs of complications.
27.
Before discharge, the nurse scheduled the client who had a colostomy for colorectal cancer for discharge instruction about resuming activities. The nurse should plan to help the client understands that:
Correct Answer
C. With counseling and medical guidance, a near normal lifestyle, including complete sexual function is possible.
Explanation
After surgery, it is important for the nurse to help the client understand that with counseling and medical guidance, a near normal lifestyle, including complete sexual function, is possible. This is because individuals with a colostomy may have concerns about their ability to engage in normal activities and maintain their quality of life. By providing counseling and medical guidance, the nurse can reassure the client that they can resume a near normal lifestyle, including sexual function, with appropriate support and guidance.
28.
The client who had transverse colostomy asks the nurse about the possible effect of the surgery on future sexual relationship. What would be the best nursing response?
Correct Answer
D. The client will be able to resume normal sexual relationships.
Explanation
The correct answer states that the client will be able to resume normal sexual relationships. This response is appropriate because it reassures the client that the surgery will not have a permanent impact on their sexual relationships. It provides the client with a positive outlook for their future and promotes a sense of normalcy.
29.
Tony returns form surgery with permanent colostomy. During the first 24 hours the colostomy does not drain. The nurse should be aware that:
Correct Answer
C. Absence of gastrointestinal motility
Explanation
The correct answer is "Absence of gastrointestinal motility." This is because the colostomy not draining for the first 24 hours indicates a lack of movement or motility in the gastrointestinal system. This could be due to the surgical procedure or the effects of anesthesia, which can temporarily slow down or halt the normal movement of the intestines.
30.
A temporary colostomy is performed on the client with colon cancer. The nurse is aware that the proximal end of a double barrel colostomy:
Correct Answer
C. Is the opening on the client’s right side
Explanation
The proximal end of a double barrel colostomy refers to the end of the colon that is closest to the beginning of the digestive tract. In this case, it is the end that is further away from the client's body. Since the question states that the colostomy is performed on the client's right side, the opening of the proximal end would also be on the right side.
31.
Which of the following is TRUE in colostomy feeding?
Correct Answer
B. Pour 30 ml of water before and after feeding administration
Explanation
Pouring 30 ml of water before and after feeding administration is true in colostomy feeding. This is done to flush the tube and ensure proper hydration. Water is poured before feeding to clear any residue and after feeding to ensure that all the food has been flushed through the tube. This helps to prevent clogging and maintain the patency of the tube.
32.
A client is scheduled to undergo an abdominal perineal resection with a permanent colostomy. Which of the following measures would be an anticipated part of the client’s preoperative care?
Correct Answer
B. Administer neomycin sulfate the evening before surgery
Explanation
Administering neomycin sulfate the evening before surgery is an anticipated part of the client's preoperative care. Neomycin sulfate is an antibiotic that is commonly given before abdominal surgeries to reduce the risk of infection. By administering the antibiotic prior to surgery, it helps to decrease the number of bacteria in the intestines, reducing the risk of contamination during the procedure. This measure is important in preventing postoperative complications and promoting successful surgical outcomes.
33.
A 58-year-old male client tells the office nurse that his wife does not let him change his colostomy bag himself. Which response by the nurse indicates as understanding of the situation?
Correct Answer
C. "You feel you need privacy when changing your colostomy?"
Explanation
The nurse's response of "You feel you need privacy when changing your colostomy?" indicates an understanding of the client's desire for privacy while changing his colostomy bag. This response acknowledges the client's feelings and allows for further exploration of his needs and concerns. It does not make assumptions or judgments about the client's wife or suggest counseling or involving the doctor, which may not be relevant to the situation.
34.
A male client with bladder cancer has had the bladder removed and an ileal conduit created for urine diversion. While changing this client’s pouch, the nurse observes that the area around the stoma is red, weeping, and painful. What should nurse Katrina conclude?
Correct Answer
B. The pouch faceplate doesn’t fit the stoma.
Explanation
The nurse should conclude that the pouch faceplate doesn't fit the stoma. The symptoms of redness, weeping, and pain around the stoma indicate that there is a poor fit between the faceplate and the stoma, causing irritation and leakage. Proper fitting of the faceplate is essential to prevent skin breakdown and discomfort for the client.