NUR105 M6.9: ATI Skills Modules: Ostomy Care
A nurse is replacing the ostomy appliance for a patient whose newly created colostomy is functioning. After removing the pouch, which of the following actions should the nurse take first?
Answer: Cleanse the stoma and the peristomal skin. NUR105 M6.9: ATI Skills Modules
The first action the nurse should take is to cleanse the stoma and the peristomal skin, as this facilitates assessment and helps prevent skin irritation.
A nurse is teaching a patient about extended-wear skin barriers. Which of the following strategies should the nurse instruct the patient to use for maximal adherence? NUR105 M6.9: ATI Skills Modules
Answer: Press gently around the barrier for 30 seconds to 1 minute.
For maximal adherence of extended-wear skin barriers, the patient should press gently around the barrier for 30 seconds to 1 minute.NUR105 M6.9: ATI Skills Modules
A nurse is providing preoperative teaching for a patient who is scheduled for the creation of a sigmoid colostomy. Which of the following information should the nurse include in the teaching?
Answer: Use irrigation to help establish a regular bowel pattern.
For a sigmoid colostomy, irrigation can help the patient establish a regular bowel pattern. An external appliance is not necessary once a regular pattern is established.
A nurse is reinforcing teaching with a patient who has colon cancer and is scheduled for a procedure to remove their entire large intestine and rectum. The nurse should reinforce with the client that they are scheduled for which of the following types of ostomy procedures?
Answer: Ileostomy.
After the removal of the entire large intestine and rectum, an ileostomy is created to divert feces from the small intestine to the abdominal surface and into an ostomy pouch.NUR105 M6.9: ATI Skills Modules
A nurse is obtaining health history from a patient who has a colostomy. The patient reports frequent episodes of loose stools over the last month but has no signs of infection or bowel obstruction. The patient reports that they have avoided participation in social activities because they are concerned about leakage. Which of the following should the nurse recommend?
Answer: Consume foods that are low in fiber content.
To thicken stool and reduce leakage, the nurse should recommend consuming foods that are low in fiber content.
A nurse is teaching a patient who has bladder cancer about urinary diversion options. The nurse should inform the patient that which of the following options will allow them to have some control over urinary elimination?
Answer: Kock’s pouch.
A Kock’s pouch is a continent ileal bladder conduit that allows the patient to self-catheterize every 2-4 hours to remove urine, giving them some control over urinary elimination.
A nurse is reinforcing teaching with a patient about replacing an ostomy pouching system. The client reports that they occasionally experience pain when removing the skin barrier. Which of the following techniques should the nurse suggest?NUR105 M6.9: ATI Skills Modules
Answer: Push the skin away from the barrier while removing it.
If the patient experiences pain during the initial release of the barrier, the nurse should suggest removing the barrier by starting in one corner and gently pulling it across the stoma while pushing the skin away from the barrier.
A nurse is teaching a patient who has a new ileostomy about preventing the excoriation and breakdown of the peristomal skin after they have returned home. Which of the following instructions should the nurse include?
Answer: Empty the pouch when it is less than half full.
To prevent excoriation and breakdown of peristomal skin, the nurse should instruct the patient to empty the pouch when it is between 1/3 to 1/2 full. Waiting until it is more than half full increases the risk of leakage and skin irritation.
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