ATI-OSTOMY CARE PRE/POST TEST
A nurse is replacing the ostomy appliance for a patient whose newly created
colostomy is functioning. After removing the pouch, which of the following
should the nurse do first?
A. Measure the stroma
B. Cover the stroma with gauze
C. Remove the backing on the skin barrier
D. Cleanse the stoma and the peristomal skin - correct answer Answer: Cleanse
the stoma and the peristomal skin
- To facilitate the nurse's assessment of the stoma and the peristomal skin, the
nurse must remove any effluent adhering to the area.
A nurse is teaching a patient with a new ileostomy about incorporating preventive
strategies at home. To prevent excoriation and breakdown of the peristomal skin,
the nurse should instruct the patient to
A. Apply hydrocortisone cream to the skin when changing the appliance.
B. Empty the pouch when it is no more than half full.
C. Wash the peristomal skin frequently with deodorizing soap and water.
D. Choose a time shortly after a meal for replacing the pouch. - correct answer
Answer: Empty the pouch when it is no more than half full
- Waiting until the pouch is more than half full increases the risk of leakage.
Ileostomy effluent is irritating to peristomal skin, so patients should replace the
pouch when it is one third to one half full.
Patients should avoid the use of soap, especially oil or lotion based soaps. They
leave a residue that can interfere with pouch adhesion and increase the risk of
leakage. They should cleanse the skin and warm tap water. For times when soap
