Ostomy Care - NCLEX Pn

Which ostomy type has the highest risk for dehydration and electrolyte imbalance?

Ileostomy. Ileostomies produce high-volume liquid output, increasing fluid and electrolyte loss, especially sodium and potassium.
Which complication is suggested when the stoma appears pulled inward below skin level?

Stoma retraction. Retraction can result from tension or poor healing, potentially leading to leakage and skin issues.
At what pouch fill level should the ostomy pouch typically be emptied to prevent leakage?

Empty when it is about $\frac{1}{3}$ to $\frac{1}{2}$ full. Emptying at this level prevents excessive weight that could pull on the seal, reducing leakage risk.
What is the expected stool consistency from an ileostomy?

Liquid to semi-liquid stool with frequent output. Ileostomy effluent comes from the small intestine, where water absorption is minimal, resulting in high-volume, watery output.
What is the correct method to measure a new stoma for sizing the barrier opening?

Use a stoma measuring guide; measure at the base. Accurate measurement at the base ensures a proper fit, preventing skin exposure or stoma trauma.
When is the best time to change an ostomy pouching system to reduce output during care?

Before meals or when peristalsis is minimal (often early morning). Timing minimizes active output, reducing mess and improving ease of application for a better seal.
Which intervention is appropriate for suspected peristomal candidiasis?

Apply antifungal powder and reapply barrier as directed. Antifungal powder treats the yeast infection while allowing barrier reapplication to maintain skin protection.
What is the recommended fit when cutting the barrier opening for a stoma?

Snug fit with about $1\text{–}2\ \text{mm}$ clearance around stoma. This clearance protects skin from effluent irritation without constricting the stoma, allowing for minor swelling.
Which action best promotes adhesion of an ostomy barrier after cleansing the skin?

Pat skin completely dry before barrier application. Dry skin ensures optimal contact for the adhesive barrier, preventing moisture-related slippage or leakage.
Which product is most appropriate to fill small peristomal skin creases and prevent leakage?

Stoma paste or moldable barrier ring. These products conform to uneven skin surfaces, creating a leak-proof seal around the stoma base.
Which symptom in an ileostomy patient most suggests bowel obstruction from food blockage?

Cramping abdominal pain with decreased or no stoma output. These signs indicate potential blockage, often from undigested food, requiring prompt intervention to prevent complications.
Which initial nursing action is appropriate for a patient reporting sudden no ileostomy output?

Assess abdominal pain/distention and notify provider promptly. Sudden cessation of output may signal obstruction, so assessment and notification facilitate timely diagnosis and treatment.
What is the primary purpose of a skin barrier (wafer) in ostomy care?

Protect peristomal skin from effluent and secure pouch. The barrier creates a protective seal against irritant stool or urine while providing a stable base for pouch attachment.
Which stoma assessment finding is expected in a healthy, newly created ostomy?

Moist, shiny, and beefy red or pink stoma. A healthy new stoma appears viable with good perfusion, indicating adequate blood supply and no signs of ischemia or infection.
Which finding indicates peristomal candidiasis rather than simple irritation?

Beefy red rash with satellite lesions and itching. Satellite lesions and itching are characteristic of yeast overgrowth, distinguishing it from contact dermatitis.
What is the best way to remove an ostomy barrier to minimize skin trauma?

Gently peel while supporting skin; use adhesive remover if needed. This technique minimizes pulling on delicate peristomal skin, reducing the risk of irritation or stripping.
Which stoma assessment finding requires immediate intervention for possible ischemia?

Dusky, pale, purple, or black stoma color. These colors suggest compromised blood flow, requiring urgent medical attention to prevent necrosis and potential stoma failure.
Which complication is suggested by a stoma that protrudes more than usual and is swollen?

Stoma prolapse. Prolapse involves telescoping of the bowel, often due to increased abdominal pressure, requiring monitoring for obstruction.
How often should a new ostomy be remeasured for resizing the barrier during healing?

Re-measure regularly; stoma size shrinks over the first weeks. Postoperative edema resolves gradually, necessitating frequent resizing to maintain a secure, protective fit.
What is the expected stool consistency from a sigmoid colostomy?

Formed stool with more predictable output. Sigmoid colostomy output reflects large intestine function, where water is absorbed, leading to more solid and regular stool.
Which diet teaching is priority for a patient with a new ileostomy to reduce dehydration risk?

Increase fluids and monitor output; replace electrolytes as needed. High fluid intake compensates for ileostomy losses, with monitoring ensuring early detection of imbalances.
Which step should you take first if the patient reports burning under the ostomy wafer?

Assess for leakage and peristomal skin breakdown. Burning often indicates effluent contact with skin, so immediate assessment identifies and addresses the underlying cause.
What is the correct skin cleansing method before applying a new ostomy barrier?

Clean with warm water; avoid oils, lotions, and harsh soap. Warm water gently removes residue without leaving films that impair adhesion, while avoiding irritants that could damage skin.
Which finding most strongly suggests a parastomal hernia?

Bulge around stoma that increases with coughing or standing. The bulge indicates bowel or omentum protrusion through the abdominal wall defect, exacerbated by intra-abdominal pressure.

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