BSN205 HALLMARK- ELIMINATION/OSTOMY ISB QUESTIONS AND ANSWERS.Buy Quality Materials!
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Course
BSN206-05
Institution
BSN206-05
BSN205 HALLMARK- ELIMINATION/OSTOMY ISB QUESTIONS AND ANSWERS.Buy Quality Materials!
If a patient had to have part of the colon (large intestine) removed, which of the following may result?
The patient could experience an acid-base imbalance.
-A primary function of the colon is secretion ...
BSN205 HALLMARK- ELIMINATION/OSTOMY ISB QUESTIONS
AND ANSWERS.Buy Quality Materials!
If a patient had to have part of the colon (large intestine) removed, which of the
following may result?
The patient could experience an acid-base imbalance.
-A primary function of the colon is secretion of bicarbonate for chloride and the release
of potassium. Any alteration in secretory function could result in an acid-base
imbalance. Another primary function of the colon is protection of the sensitive tissue
lining of the colon through the release of mucus. If a portion of the colon is removed,
there would be fewer mucus-secreting cells available. The colon also absorbs water,
sodium, and chloride. If less water is absorbed, the patient would be at increased risk
for diarrhea and an electrolyte imbalance.
A nurse is admitting a patient to the unit. The nurse is aware that the patient is at
increased risk for constipation if the following are present in the patient's health
history or admission assessment:
The patient is an elderly woman.
The patient takes opioids for chronic back pain.
The patient takes daily iron and calcium supplements.
-As a person ages, peristalsis slows, which increases the risk for constipation. Opioids,
iron supplements, and calcium supplements slow colonic action. Laxative misuse is a
common cause for constipation. A diet high in animal fats and low in fiber and fluid
increases the risk for constipation. Lengthy bed rest or lack of regular exercise are risk
factors for constipation.
A student nurse is studying the GI system in preparation for an exam. Which
statement indicates correct understanding?
The ascending colon would be found in the right side of the patient s abdomen.
-The ascending colon is found in the right side of the abdomen. The order of the colon is
ascending colon, transverse colon, descending colon, sigmoid colon (then rectum and
anus). Most nutrients are absorbed in the small intestine; most water is absorbed in the
large intestine. A patient's heart rate may decrease with manipulation of the rectum that
stimulates the vagus nerve (known as a vagal response). Opioids (narcotic analgesics)
cause constipation because of decreasing peristalsis; antibiotic therapy places a person
at risk for diarrhea as a result of altered normal flora (as seen with Clostridium difficile
infection).
An increase in venous pressure caused by liver disease can result in the
development of:
Hemorrhoids
- Pressure leading to hemorrhoids can also occur from straining during defecation and
from pregnancy.
The comatose patient in the intensive care unit (ICU), who has not had a bowel
movement in 4 days, suddenly is incontinent of liquid stool. What should the
nurse suspect?
, Impaction
-Prolonged constipation followed by diarrhea that seeps around the impacted stool are
symptoms of a fecal impaction.
The nurse is monitoring the patient for a possible vagal response while removing
a fecal impaction. If the patient had a vagal response, what would the nurse most
likely observe?
A decrease in heart rate.
A patient has a loop colostomy. The patient complains that the distal stoma looks
like it is secreting mucus. What is your best response?
"The distal stoma may secrete mucus and that would be normal."
-The distal stoma is the nonfunctional end. It may secrete mucus. The proximal stoma
of the loop colostomy is the functional end that excretes effluent. A loop colostomy is a
bowel diversion and is without connection to the urinary system.
A patient has been admitted for surgery for a colostomy. The patient states, "I
can't believe this has happened to me." What is the nurse's best response?
"It will be a change for you, but a normal lifestyle is still possible. What concerns you the
most?"
-An important aspect of patient teaching by you, the nurse, is to help the ostomy patient
develop acceptance of a change in body image and realization that a normal lifestyle is
still possible. Asking "why" can make the patient feel defensive. Telling the patient not to
worry fails to acknowledge their feelings and is nontherapeutic. Although determining
whether the patient has a support system is important, asking about how the family
feels ignores the patient's feelings.
A patient is scheduled to have an ileostomy. The patient asks, "Will I always have
to wear a pouch?" What is the nurse's best response?
"Unless an internal pouch is surgically created, the effluent of an ileostomy is very liquid
and must be pouched at all times."
-With an ileostomy the fecal effluent leaves the body before it enters the colon, creating
frequent, liquid stools. An ileostomy drains fecal effluent that is watery to thick and
contains some digestive enzymes. A colostomy of the sigmoid colon generally results in
formed stool.
The nurse is pouching an enterostomy. Assuming all other steps are performed
correctly, which of the following steps is incorrect?
The nurse cleans the peristomal skin vigorously with warm tap water, selects a pouch,
removes the backing and cuts the opening on the pouch to one-quarter inch larger than
the stoma.
-To correctly perform the procedure, the nurse performs hand hygiene, auscultates for
bowel sounds, assesses the skin barrier and pouch for leakage, and positions the
patient comfortably in a supine or semireclining position. The nurse repeats hand
hygiene, applies clean gloves, and places a waterproof pad under the patient. The
nurse gently cleans the peristomal skin and pats dry. The nurse measures the stoma
and cuts the opening on the pouch to the size of the stoma before removing the
backing. The nurse applies the pouch over the stoma, pressing firmly around stoma and
outside edges, and has the patient hold hand over pouch to apply heat to secure seal.
The nurse closes the end of the pouch with a clip, removes drape, removes gloves,
performs hand hygiene, and documents the procedure.
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