30 Questions
How should a nurse position a constipated client for digital removal of stool?
Left lateral side-lying position
What intervention should a nurse perform when irrigating a client’s sigmoid colostomy?
Advising the client to hold the breath if cramping occurs during instillation of the solution
When should a urinary stoma collection bag be changed according to best practice?
When it is one-third full to prevent pulling of the appliance and leakage
What would be the best recommendation for a client with a urinary stoma regarding changing the appliance?
Change it every 5 to 7 days for proper care
What is an essential step when inserting an irrigation tube for a sigmoid colostomy?
Using minimal force during insertion to prevent injury
Why is it important to hang the irrigation solution 18 inches above the client’s torso during sigmoid colostomy irrigation?
To ensure proper infusion of the solution into the stoma
What is the most appropriate action for the nurse to take when assessing a client with bladder cancer and ureterostomy?
Assess the stoma for a purple discoloration.
What should be the nurse's priority action when caring for a client with ulcerative colitis and a transverse colostomy?
Monitoring for a purple discoloration of the stoma.
What interpretation should the nurse provide for malodorous flatus passing from the stoma in a client who recently had a colostomy created?
It signifies early signs of ischemic bowel.
Which complication should the nurse prioritize assessing for in a client with Crohn's disease post-ileostomy creation surgery?
Intestinal obstruction
What should be included in the education plan for a client with bladder cancer and ureterostomy regarding stoma care?
Empty the urinary collection bag when it is half full.
When caring for a client with ulcerative colitis and a transverse colostomy, what observation indicates proper adaptation to the stoma?
Visible semiformed stool in the ostomy pouch.
What color of a urinary stoma is associated with ischemia?
Purple
Which observation requires immediate surgeon notification?
Purple discoloration of the stoma
What does a beefy red and shiny stoma indicate?
Normal and expected
Which statement does not require as immediate attention as purple discoloration of the stoma?
Semiformed stool is a normal finding
What color is NOT associated with ischemia of a urinary stoma?
Beefy red
In the care of a urinary stoma, which finding indicates the need for immediate surgeon notification?
Dusky color of the stoma
What is the most ideal time to change the appliance for a client with a urinary diversion?
Morning
How often should the pouch of a urinary diversion be changed?
Every 5-7 days
What is the recommended method to clean the stoma for a client with a urinary diversion?
Nonresidue soap and water
How much larger than the stoma should the skin barrier be cut for a urinary diversion?
3 millimeters larger
Why should clients with urinary diversions be encouraged to take slow, deep breaths if cramping occurs?
To alleviate discomfort and promote relaxation
What are urinary diversions and stomas usually related to in terms of health problems?
Gastrointestinal disorders
Which position is ideal for digital removal of stool based on the text?
Left lateral sidelying position
What type of catheter is necessary for continuous bladder irrigation, as mentioned in the text?
Triple-lumen catheter
In which position should the client be placed for digital removal of stool?
Right lateral sidelying position
What is the primary function of a triple-lumen catheter used for continuous bladder irrigation?
Facilitates irrigation solution instillation
Which nursing process is involved in determining the correct position for digital removal of stool?
Assessment
What is the main reason for using a left lateral sidelying position for digital removal of stool?
Follows the anatomical curvature of the colon
Study Notes
Positioning for Digital Removal of Stool
- For digital removal of stool, the client should be positioned in the left lateral side-lying position, which follows the anatomical curvature of the colon.
Irrigating a Sigmoid Colostomy
- To irrigate a sigmoid colostomy, the nurse should plan to instill 500 to 1000 mL of lukewarm tap water through the stoma.
- The nurse should hang the irrigation solution so that the bottom of the bag is 18 inches above the client's torso.
- The nurse should insert the irrigation tube with a small amount of force and a twisting motion into the stoma and unclamp the tubing to allow the solution to flow into the stoma.
Changing a Urinary Collection Bag and Appliance
- The urinary collection bag needs to be changed when it is one-third full to prevent pulling of the appliance and leakage.
- The client should clean the stoma with both non-residue soap and water, not just water.
- The skin barrier should be cut no more than 3 millimeters larger than the stoma to prevent urine leakage and irritation of the exposed skin.
- The pouch needs to be changed every 5 to 7 days.
Care of a Urinary Diversion
- The client should be educated on the proper care of the urinary stoma, including cleaning the stoma with non-residue soap and water, and changing the appliance and pouch regularly.
- The client should be advised to change the appliance in the morning, not at night.
- The client should empty the urinary collection bag when it is one-third full.
Care of a Client with a Colostomy
- A beefy red and shiny stoma is normal and expected.
- Purple discoloration of the stoma indicates ischemia and requires immediate attention from the surgeon.
- Skin excoriation around the stoma needs to be addressed and treated.
- Semiformed stool is a normal finding in the ostomy pouch.
Complications of Ileostomy Surgery
- The most frequent complication of ileostomy surgery is intestinal obstruction.
- Other complications may include folate deficiency, malabsorption of fat, and electrolyte imbalances.
Test your knowledge on urinary stoma care and nursing interventions with these practice questions. Evaluate your understanding of post-cystectomy care and client education. Get ready for your nursing exams with this quiz!
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