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Ostomy Care Exam Questions And Accurate Answers
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Ostomy Care Exam Questions And Accurate AnswersHere is your scenario. You are a nurse working on a medical-surgical unit. One of your
clients is a 30-year-old female who was transferred to your unit from the post anesthesia
care unit after ileostomy surgery for Crohn's disease. You perform a postoperative
assessment and find that the client is alert, oriented and responding appropriately.
However, as you pull the sheet down to visualize her abdomen, you note a significant
clinical manifestation. Her ileostomy pouch is filled with a large amount of bright, red
blood.
What would be the first type of output that is expected from an ileostomy
postoperatively?
Select a response
A. A loose, dark green liquid that may contain some blood
B. Serous drainage
C. Formed to semiformal stool
D. Pasty yellow-brown stool
A. A loose, dark green liquid that may contain some blood
A - CORRECTYes. You have chosen the correct answer. This is the first type of output
that is seen from an ileostomy. As time progresses the output will thicken and become
pasty and yellow-green or yellow-brown.
You have determined that you must assess the client's abdomen. You inspect,
auscultate, and palpate the abdomen. You observe that the abdomen is slightly rigid, but
,not distended. The abdominal incision, which has been repaired with staples, is clean,
dry, and intact. Bowel sounds are hypoactive in all four quadrants.
Which of the following would you assess next?
Choose one of the following options.
A. Her urine output
B. The suture line
C. The stoma
B The suture line
B - CORRECTYes. You have selected the correct answer. After inspecting the client for
abdominal bleeding, inspect the suture line, which is also called the mucocutaneous
junction. Monitor for frank bleeding from trauma to the mesenteric artery. Frank
bleeding is a medical emergency. Notify the surgeon immediately.
You carefully examine the suture line but don't find any bleeding, and it is intact and dry
around all the edges.
Which examination would you conduct next?
Choose one of the following options.
A. Her urine output
, B. The stoma
B. The stoma
B - CORRECTYes. You have selected the correct answer. Stoma for bleeding should be
checked. Trauma to the stoma mucosa may also be the cause of bleeding.
You note the stoma to be pink, moist, and edematous without any evidence of bleeding
or trauma. You find only watery greenish effluent from the stoma and no other blood.
Once you have sought the source of bleeding, you reassess the patient's status
including vital signs and urine output for evidence of hemorrhage. Reduction in urine
output could be related to hemorrhagic shock. Bloody urine can be the result of damage
to the kidneys or urinary system during the surgery or it may be due to systemic causes
related to disease underlying or pharmacologic therapy. The patient's output is >30 mL
per hour and the color of her urine is clear yellow. You review her medications looking
for the recent use of anti-inflammatory or antiplatelet medications that increase the risk
of bleeding. After confirming that she is not taking any of these medications, you
conclude that the blood has traversed the gastrointestinal tract from the internal
mucosa. You notify the surgeon of this as she arrives at the unit to assess the patient.
You continue to monitor the patient's vital signs, abdomen, stoma, and effluent
frequently to confirm that the bleeding has ceased.
ASSESSMENT
Your patient's ostomy pouch is now one third full with watery green effluent. You decide
to discuss the selection of a pouching system with the patient.
Which type of ostomy pouching system is appropriate for this client at this time?
Select one of the following options
A.Pouching system without a skin barrier
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