NUR 150 - SESSION 3 - STOMA CARE

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MULTIPLE CHOICE QUESTIONS

Nurse Max is caring for a client with permanent / end colostomy and is now for his
first-time irrigation. Then suddenly, the client verbalizes, “I feel like that there is a
train inside my tummy!!” What is the highest priority nursing action that nurse Max
should undertake?

Reassure that the client is in good hand and continue with the irrigation.

Render therapeutic communication and allow the client to verbalize his feelings.

Render therapeutic touch and turn the regulator off to allow the patient to rest.

Notify the primary healthcare provider.

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The common underlying conditions resulting in the need for stoma surgery are:
(Select all that apply.)

Crohn’s disease

Celiac disease

Colorectal cancer

Clostridium difficile infection

Bladder cancer

Gynaecological cancers

It is an ostomy pouch system designed for clients who usually develop sore and
skin irritation.

One-piece system

Two-piece system

Three-piece system

Four-piece system

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It is a surgical procedure that brings one end of the large intestine out through the
abdominal wall and during this procedure, one end of the colon is diverted through
an incision in the abdominal wall to create a stoma.

Ileostomy

Gastrostomy

Colostomy

Urostomy

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Nurse Max is caring for a client with ileostomy and noticed that the effluent is
loose. What action that Nurse Max should undertake?

Assess the vital signs including temperature, respiratory rate, pulse rate, blood
pressure and oxygen saturation.

Administer lactulose 30 mL STAT.

Notify immediately this pertinent data to the primary healthcare provider.

Observe and document the characteristics and consistency.

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What is the highest priority nursing action for a client with a urostomy/ ileal conduit
prior to discharge?

Restoring sexual health and intimacy.

Strengthening the linkages to the community health facility.

Preparing the client for advance directives.

Promoting independency and self-care.

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Water-soluble lubricant is preferred to be used during the insertion of the cone to

the stoma during irrigation. What is the reason behind this?

It has an antiseptic or bactericidal effect in the stoma.

It eases the friction and thus helps with a smooth insertion of the cone.

It helps not to cause borborygmi sound

It numbs the area and thus helps with a smooth insertion of the cone.

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Below are the types of ostomies. Select all that apply.

Urostomy

Percutaneous Endoscopic Gastrostomy

Colonoscopy

Ileostomy

Colostomy
 Encourage the client to ambulate prior to detaching the irrigation sleeve/sheath.
What is the clinical reasoning for this action?

Ambulation stimulates peristaltic movement and completion of the irrigation return.

Ambulation aids during cramping.

Ambulation stops the tenderness around the stoma.

Ambulation prevents the proliferation of pathogenic bacteria

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What type of appliance is best for clients with large bowel ostomy?

Open appliance

Closed appliance

Drainable appliance

Urostomy appliance

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