TEST BANK FOR NURSING INTERVENTIONS AND CLINICAL SKILLS 7TH EDITION BY POTTER
Chapter 21: Ostomy Care Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The patient notices that the newly formed ileostomy stoma is pinkish red and slightly puffy.
Which information would the nurse include during patient teaching? a. This is what a new healthy stoma looks like. b. Any bleeding indicates that a problem is present. c. Healthy stomas are usually pale pink and flat. d. There should be very little drainage from the stoma. ANS: A
The nurse instructs the patient to expect a healthy stoma to be pinkish red, indicating adequate oxygenated blood flow, and slightly puffy because it is new. Since the stoma is highly vascular, there may be a little blood. A pale pink stoma indicates decreased blood flow. The stoma should be raised. New stomas drain and are pouched immediately after being created. DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity TOP: Integrated Process: Teaching-Learning 2. A patient with a colostomy made as a result of abdominal trauma 4 days ago closes eyes
during stoma care. What patient outcome is most important for the nurse to help the patient achieve? a. The patient needs no assistance to perform this procedure within a few days. b. The patient will ask questions about what clothing to wear before discharge. N c. The patient touches the stoma while looking at it within the next 2 days. d. The patient’s family learns how to pouch the stoma within 1 week. ANS: C
Patients usually need time to adjust to an abrupt body image change and a change in bodily function. Looking at the stoma and touching it would indicate the beginning of adapting to the changes. The patient needs to be able to be independent eventually in caring for his ostomy, but it is not expected that he would be caring for the stoma within a few days. The patient needs to talk about what type of clothing will work with the stoma well before discharge but adjusting to the change in his body must come first. DIF: Cognitive Level: Evaluating TOP: Nursing Process: Evaluation
OBJ: NCLEX: Psychosocial Integrity
3. The nurse is teaching the patient how to size the skin barrier around the stoma. Which
instructions does the nurse include? a. Use the measurement guide for a proper fit. b. Extend the skin barrier to cover the incisional area. c. Make a wick from toilet tissue before changing the skin barrier. d. Trim the skin barrier to fit slightly over the stoma margin. ANS: A
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