The nurse recognizes water effluent coming from the ostomy is indicative of what
location:
Ilial portion of the small intestine
The nurse notices that the effluent ranges from a thick liquid to a semi-formed stool,
indicative of which location:
transverse or ascending colon
The nurse is caring for a patient who had a colostomy placed 5 days earlier. The nurse
notes that the stoma is red and moist. Which action should the nurse take?
Note the condition of the stoma in her notes.
In caring for a patient who had a fecal surgical diversion, which nursing intervention is
essential?
Place a pouch over the newly created stoma.
When planning care for a patient who has a colostomy, which intervention is important
for the nurse to perform when pouching the colostomy?
Leave an intact skin barrier in place for 3-7 days.
When providing care for a patient with a colostomy or ileostomy, the nurse recognizes
that which is an expected assessment finding?
A moist, reddish-pink stoma.
The nurse is caring for a preterm infant in the neonatal ICU who has multiple stomas.
Given the uniqueness of infants, which action is essential for the nurse to take?
Use a pouch that can accommodate increased amounts of flatus.
In caring for a patient who has a pouching for a noncontinent urinary diversion, which
nursing intervention is essential?
Empty the pouch when it is 1/3 - 1/2 full.
When assessing the patient with a noncontinent urinary diversion, the nurse finds that
the urine has mucous shreds. What action should the nurse take?
Note the characteristics of the urine in her notes.
The nurse has removed the patient's old urostomy pouch and is attempting to measure
the stoma opening for placement of a new pouch. Which action should the nurse take
next?
Place rolled gauze at the stoma opening.
A patient who has a urostomy is being discharged to home. Which instruction will the
nurse provide to the patient?
Shower without covering the pouch.
The nurse is caring for a patient who has a urinary diversion. She notices that the
patient has a temp of 102 and foul-smelling urine. What action should the nurse take?
Notify the physician
The nurse is preparing to catheterize a patient who has a urostomy and uses a two-
piece pouch system. The nurse should take which action:
Remove the pouch and leave the barrier attached.
The nurse is caring for a patient who will have surgery in the morning to have a
colostomy placed. The nurse is aware of teh physical and emotional stresses that the
patient will experience, including: