Elimination Saunders Practice Questions:  ex 2 med surg 1

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Questions and Answers

Which statement by the client indicates the need for more education about urinary stoma care?

  • I empty the urinary collection bag when it is two-thirds full.
  • I change the appliance in the morning.
  • When I’m in the shower, I direct the flow of water away from my stoma.
  • I change my pouch every week. (correct)

What observation requires immediate notification of the surgeon in a client with a transverse colostomy?

  • Stoma has a purple discoloration. (correct)
  • Semiformed stool is noted in the ostomy pouch.
  • Stoma is beefy red and shiny.
  • Skin excoriation is noted around the stoma.

In a client with a new colostomy passing malodorous flatus, what is the correct interpretation by the nurse?

  • The client should not have the nasogastric tube removed.
  • This indicates inadequate preoperative bowel preparation. (correct)
  • This is a normal, expected event.
  • The client is experiencing early signs of ischemic bowel.

After creating an ileostomy in a client with Crohn’s disease, what is the most frequent complication to assess for?

<p>Intestinal obstruction (B)</p> Signup and view all the answers

What color would indicate ischemia of a urinary stoma?

<p>Purple (A)</p> Signup and view all the answers

Which type of stool is considered normal for a urinary stoma?

<p>Semiformed (C)</p> Signup and view all the answers

What type of skin condition requires immediate attention for a urinary stoma?

<p>Excoriation (D)</p> Signup and view all the answers

Which color of the urinary stoma would be considered normal and expected?

<p>Beefy red (A)</p> Signup and view all the answers

What strategic word should be noted when focusing on selecting the incorrect client statement about a urinary stoma?

<p>Understanding (B)</p> Signup and view all the answers

Which phrase would direct you to the correct option when evaluating client needs related to a urinary stoma?

<p>&quot;Surgeon notification&quot; (B)</p> Signup and view all the answers

What action requires a need for further teaching in indwelling urinary catheter care?

<p>Inflating the balloon without advancing the catheter (B)</p> Signup and view all the answers

In which situation would a nurse not need to further teach a client about indwelling urinary catheter care?

<p>The balloon inflates successfully in the bladder without any pain (B)</p> Signup and view all the answers

What should a nurse do if a client experiences pain during inflation of an indwelling urinary catheter balloon?

<p>Advance the catheter farther into the urethra (D)</p> Signup and view all the answers

Why might a client experience pain during inflation of an indwelling urinary catheter balloon?

<p>The catheter tip is located in the urethra instead of the bladder (B)</p> Signup and view all the answers

What is a crucial step a nurse should take if a client complains of pain during indwelling urinary catheter care?

<p>Assess and address the cause of pain immediately (C)</p> Signup and view all the answers

When should a nurse attempt to inflate the balloon of an indwelling urinary catheter?

<p>Before advancing the catheter into the bladder (C)</p> Signup and view all the answers

What is the ideal position for performing digital removal of stool?

<p>Right lateral side-lying position (B)</p> Signup and view all the answers

Which type of catheter is necessary for continuous bladder irrigation?

<p>Triple-lumen catheter (C)</p> Signup and view all the answers

In what position should a client be placed for digital removal of stool?

<p>Right lateral side-lying position (D)</p> Signup and view all the answers

What is the purpose of a triple-lumen catheter used for continuous bladder irrigation?

<p>To allow balloon inflation, instillation of irrigation solution, and drainage (A)</p> Signup and view all the answers

What cognitive skill is involved in generating solutions for procedures like digital removal of stool?

<p>Problem-solving (B)</p> Signup and view all the answers

Which concept is primarily related to the correct positioning during nursing procedures?

<p>Body Mechanics (C)</p> Signup and view all the answers

What is the primary reason to eliminate option 2 from the remaining options?

<p>It advises against holding the breath when cramping occurs (B)</p> Signup and view all the answers

Why is it essential for clients with urinary diversions to clean the stoma with nonresidue soap and water?

<p>To prevent skin barrier breakdown (D)</p> Signup and view all the answers

What is the recommended frequency for changing the pouch of a urinary diversion?

<p>Once a week (C)</p> Signup and view all the answers

Why should the skin barrier be cut no more than 3 millimeters larger than the stoma for a urinary diversion?

<p>To minimize urine leakage and skin irritation (C)</p> Signup and view all the answers

Why is it recommended to change the appliance over the stoma in the morning rather than at night?

<p>To match the body's natural rhythms for optimal healing (D)</p> Signup and view all the answers

What is a key reason for educating clients on proper care of a urinary stoma?

<p>To improve client engagement in self-care practices (B)</p> Signup and view all the answers

Flashcards

Urinary stoma pouch change frequency

A urinary stoma pouch should be changed once a week.

Indication for stoma care education

A client stating they change their pouch every week may need more education.

Transverse colostomy concern

Purple discoloration of the stoma requires immediate notification of the surgeon.

Malodorous flatus interpretation

Malodorous flatus indicates inadequate preoperative bowel preparation.

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Complication after ileostomy

Intestinal obstruction is the most frequent complication after creating an ileostomy.

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Urinary stoma ischemia color

A purple color indicates ischemia of a urinary stoma.

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Normal stool for urinary stoma

Semiformed stool is considered normal for a urinary stoma.

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Skin condition for urinary stoma care

Excoriation requires immediate attention for a urinary stoma.

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Normal urinary stoma color

Beefy red color is considered normal and expected for a urinary stoma.

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Client statement focus

The word 'understanding' is key when selecting an incorrect client statement about a urinary stoma.

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Client needs evaluation phrase

The phrase 'Surgeon notification' directs to the correct option when evaluating client needs related to a urinary stoma.

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Incorrect indwelling catheter care

Inflating the balloon without advancing the catheter requires further teaching.

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Indwelling catheter care success

The balloon inflates successfully in the bladder without pain indicates no further teaching is needed.

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Pain during catheter inflation

If pain occurs during inflation of an indwelling urinary catheter balloon, advance the catheter farther into the urethra.

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Cause of pain during catheter inflation

The catheter tip located in the urethra instead of the bladder may cause pain during inflation.

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Immediate action for catheter pain

A nurse should assess and address the cause of pain immediately if a client complains during catheter care.

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Timing for inflating catheter balloon

A nurse should attempt to inflate the balloon of an indwelling urinary catheter before advancing it into the bladder.

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Position for digital stool removal

The right lateral side-lying position is ideal for performing digital removal of stool.

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Catheter type for bladder irrigation

A triple-lumen catheter is necessary for continuous bladder irrigation.

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Repositioning for stool removal

The client should be placed in the right lateral side-lying position for digital removal of stool.

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Purpose of a triple-lumen catheter

A triple-lumen catheter allows balloon inflation, instillation of irrigation solution, and drainage.

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Cognitive skill for stool removal

Problem-solving is involved in generating solutions for procedures like digital removal of stool.

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Correct positioning concept

Body mechanics is primarily related to the correct positioning during nursing procedures.

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Eliminating option in assessments

It is essential to eliminate an option that advises against holding the breath when cramping occurs.

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Cleaning stoma rationale

Clients with urinary diversions must clean the stoma with nonresidue soap and water to prevent skin barrier breakdown.

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Skin barrier size recommendation

The skin barrier should be cut no more than 3 millimeters larger than the stoma to minimize urine leakage and skin irritation.

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Optimal time for appliance change

Changing the appliance over the stoma in the morning is recommended for optimal healing.

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Client education purpose

Educating clients on proper care of a urinary stoma improves engagement in self-care practices.

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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.

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