28 Questions
Which statement by the client indicates the need for more education about urinary stoma care?
I change my pouch every week.
What observation requires immediate notification of the surgeon in a client with a transverse colostomy?
Stoma has a purple discoloration.
In a client with a new colostomy passing malodorous flatus, what is the correct interpretation by the nurse?
This indicates inadequate preoperative bowel preparation.
After creating an ileostomy in a client with Crohn’s disease, what is the most frequent complication to assess for?
Intestinal obstruction
What color would indicate ischemia of a urinary stoma?
Purple
Which type of stool is considered normal for a urinary stoma?
Semiformed
What type of skin condition requires immediate attention for a urinary stoma?
Excoriation
Which color of the urinary stoma would be considered normal and expected?
Beefy red
What strategic word should be noted when focusing on selecting the incorrect client statement about a urinary stoma?
Understanding
Which phrase would direct you to the correct option when evaluating client needs related to a urinary stoma?
"Surgeon notification"
What action requires a need for further teaching in indwelling urinary catheter care?
Inflating the balloon without advancing the catheter
In which situation would a nurse not need to further teach a client about indwelling urinary catheter care?
The balloon inflates successfully in the bladder without any pain
What should a nurse do if a client experiences pain during inflation of an indwelling urinary catheter balloon?
Advance the catheter farther into the urethra
Why might a client experience pain during inflation of an indwelling urinary catheter balloon?
The catheter tip is located in the urethra instead of the bladder
What is a crucial step a nurse should take if a client complains of pain during indwelling urinary catheter care?
Assess and address the cause of pain immediately
When should a nurse attempt to inflate the balloon of an indwelling urinary catheter?
Before advancing the catheter into the bladder
What is the ideal position for performing digital removal of stool?
Right lateral side-lying position
Which type of catheter is necessary for continuous bladder irrigation?
Triple-lumen catheter
In what position should a client be placed for digital removal of stool?
Right lateral side-lying position
What is the purpose of a triple-lumen catheter used for continuous bladder irrigation?
To allow balloon inflation, instillation of irrigation solution, and drainage
What cognitive skill is involved in generating solutions for procedures like digital removal of stool?
Problem-solving
Which concept is primarily related to the correct positioning during nursing procedures?
Body Mechanics
What is the primary reason to eliminate option 2 from the remaining options?
It advises against holding the breath when cramping occurs
Why is it essential for clients with urinary diversions to clean the stoma with nonresidue soap and water?
To prevent skin barrier breakdown
What is the recommended frequency for changing the pouch of a urinary diversion?
Once a week
Why should the skin barrier be cut no more than 3 millimeters larger than the stoma for a urinary diversion?
To minimize urine leakage and skin irritation
Why is it recommended to change the appliance over the stoma in the morning rather than at night?
To match the body's natural rhythms for optimal healing
What is a key reason for educating clients on proper care of a urinary stoma?
To improve client engagement in self-care practices
Study Notes
Care of a Urinary Stoma
- A beefy red and shiny stoma is normal and expected.
- Purple discoloration of the stoma indicates ischemia and requires immediate notification of the surgeon.
- Skin excoriation around the stoma needs to be addressed and treated, but does not require immediate attention.
Urinary Catheter Care
- If the client complains of pain during inflation of the balloon, the nurse should allow the fluid injected into the balloon to drain back into the syringe attached to the balloon inflation port.
- Then, the nurse should advance the catheter farther into the urethra to the bladder and attempt to inflate the balloon again.
Digital Removal of Stool
- The client should be placed in the left lateral side-lying position for digital removal of stool, as this position follows the anatomical curvature of the colon.
Urinary Stoma Care Education
- The client should change the appliance every 5 to 7 days, not weekly.
- The client should change the appliance in the morning, not at night.
- The client should empty the urinary collection bag when it is two-thirds full.
- The client should direct the flow of water away from the stoma when showering.
Complications of Ileostomy Surgery
- The most frequent complication of ileostomy surgery is intestinal obstruction.
Interpretation of Malodorous Flatus
- Passing malodorous flatus from the stoma 2 days after surgery is a normal, expected event.
Test your knowledge on urinary stoma care with practice questions from the Saunders comprehensive review for the NCLEX-RN exam. Assess your understanding of changing pouches, emptying collection bags, appliance changes, and protecting the stoma during showering.
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