ATI Skills Module 3.0: Ostomy Care Questions and Verified Answers and Rationale

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ATI Skills Module 3.0: Ostomy Care Questions and Verified Answers and Rationale A nurse is replacing the ostomy appliance for a patient whose newly created colostomy is functioning. After removing th... e pouch, which of the following actions should the nurse take first? A. Measure the stoma. B. Cover the stoma with gauze. C. Remove the backing on the skin barrier D. Cleanse the stoma and the peristomal skin. ✔Ans✔ A. Cleanse the stoma and the peristomal skin. Rationale: First action nurse should take is to remove any effluent adhering to the stoma & peristomal skin to facilitate assessment of area 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? A. Use an oil-based lotion on the peristomal area. B. Apply the skin barrier while the skin is slightly moist. C. Leave the residue from the previous appliance on the skin. D. Press gently around the barrier for 30 seconds to 1 min. ✔Ans✔ D. Press gently around the barrier for 30 seconds to 1 min. Rationale: The nurse should instruct the client to press gently around to barrier for 30 seconds to 1 min because the pressure-sensitive tackifiers and heat-sensitive polymers of the skin barrier require adequate pressure and warmth (from the fingers) to ensure adherence. A nurse is providing preoperative teaching for a patient who is scheduled for creation of a sigmoid colostomy. Which of the following info should the nurse include in the teaching? A. Expect the effluent from the sigmoid colostomy to be loose and continuous. B. Use irrigation to help establish a regular bowel pattern. C. Change the stoma's appliance every other day. D. Expect effluent from the newly created stoma within 24 hr after surgery. ✔Ans✔ B. Use irrigation to help establish a regular bowel pattern. Rationale: Clients with sigmoid colostomies can use irrigation to help control the passage of stool. Once the client has established a regular bowel pattern, the they can wear a stoma cap over the site, but they do not need an external appliance. [Show More]

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