MSN Exam for Colostomy

1) The nurse knew that the normal color of Michiel’s stoma should be

  1. Brick Red
  2. Gray
  3. Blue
  4. Pale Pink

2) The nurse is performing a colostomy irrigation on a male client. During the irrigation, the client begins to complain of abdominal cramps. What is the appropriate nursing action?

  1. Notify the physician
  2. Stop the irrigation temporarily
  3. Increase the height of the irrigation
  4. Medicate for pain and resume the irrigation

3) The nurse is caring for a client with a colostomy. The client tells the nurse that he makes small pin holes in the drainage bag to help relieve gas. The nurse should teach him that this action:

  1. destroys the odor-proof seal
  2. wont affect the colostomy system
  3. is appropriate for relieving the gas in a colostomy system
  4. destroys the moisture barrier seal

4) The nurse will start to teach Michiel about the techniques for colostomy irrigation. Which of the following should be included in the nurse’s teaching plan?

  1. Use 500 ml to 1,000 ml NSS
  2. Suspend the irrigant 45 cm above the stoma
  3. Insert the cone 4 cm in the stoma
  4. If cramping occurs, slow the irrigation

5) Nurse Michelle should know that the drainage is normal 4 days after a sigmoid colostomy when the stool is:

  1. Green liquid
  2. Solid formed
  3. Loose, bloody
  4. Semiformed

6) Discharge instructions for a patient who has been operated on for colorectal cancer include irrigating the colostomy. The nurse knows her teaching is effective when the patient states he’ll contact the doctor if:

  1. He experiences abdominal cramping while the irrigant is infusing
  2. He has difficulty inserting the irrigation tube into the stoma
  3. He expels flatus while the return is running out
  4. He’s unable to complete the procedure in 1 hour

7) The nurse is teaching a female client how to perform a colostomy irrigation. To enhance the effectiveness of the irrigation and fecal returns, what measure should the nurse instruct the client to do?

  1. Increase fluid intake
  2. Place heat on the abdomen
  3. Perform the irrigation in the evening
  4. Reduce the amount of irrigation solution

8) When preparing to teach a client with colostomy how to irrigate his colostomy, the nurse should plan to perform the procedure:

  1. When the client would have normally had a bowel movement
  2. After the client accepts he had a bowel movement
  3. Before breakfast and morning care
  4. At least 2 hours before visitors arrive

9) The nurse teaches the patient whose surgery will result in a sigmoid colostomy that the feces expelled through the colostomy will be

  1. solid.
  2. semi-mushy.
  3. mushy.
  4. fluid.

10) The nurse is caring for a male client postoperatively following creation of a colostomy. Which nursing diagnosis should the nurse include in the plan of care?

  1. Sexual dysfunction
  2. Body image, disturbed
  3. Fear related to poor prognosis
  4. Nutrition: more than body requirements, imbalanced

11) Tony returns form surgery with permanent colostomy. During the first 24 hours the colostomy does not drain. The nurse should be aware that:

  1. Proper functioning of nasogastric suction
  2. Presurgical decrease in fluid intake
  3. Absence of gastrointestinal motility
  4. Intestinal edema following surgery

12) When irrigating a colostomy, the nurse lubricates the catheter and gently inserts it into the stoma no more than _______ inches

  1. 3”
  2. 2”
  3. 4”
  4. 5”

13) The next day, the nurse will assess Michiel’s stoma. The nurse noticed that a prolapsed stoma is evident if she sees which of the following?

  1. A sunken and hidden stoma
  2. A dusky and bluish stoma
  3. A narrow and flattened stoma
  4. Protruding stoma with swollen appearance

14) Michiel asked the nurse, what foods will help lessen the odor of his colostomy. The nurse best response would be

  1. Eat eggs
  2. Eat cucumbers
  3. Eat beet greens and parsley
  4. Eat broccoli and spinach

15) When observing an ostomate do a return demonstration of the colostomy irrigation, the nurse notes that he needs more teaching if he:

  1. Stops the flow of fluid when he feels uncomfortable
  2. Lubricates the tip of the catheter before inserting it into the stoma
  3. Hangs the bag on a clothes hook on the bathroom door during fluid insertion
  4. Discontinues the insertion of fluid after only 500 ml of fluid has been instilled

16) A client is scheduled to undergo an abdominal perineal resection with a permanent colostomy. Which of the following measures would be an anticipated part of the client’s preoperative care?

  1. Keep the client NPO for 24 hrs before surgery
  2. Administer neomycin sulfate the evening before surgery
  3. Inform the client that total parenteral nutrition will likely be implemented after surgery
  4. Advise the client to limit physical activity

17) A client with colostomy refuses to allow his wife to see the incision or stoma and ignores most of his dietary instructions. The nurse on assessing this data, can assume that the client is experiencing:

  1. A reaction formation to his recent altered body image.
  2. A difficult time accepting reality and is in a state of denial.
  3. Impotency due to the surgery and needs sexual counseling
  4. Suicide thoughts and should be seen by psychiatrist

18) The nurse should insert the colostomy tube for irrigation at approximately

  1. 1-2 inches
  2. 3-4 inches
  3. 6-8 inches
  4. 12-18 inches

19) SITUATION: Michiel, A male patient diagnosed with colon cancer was newly put in colostomy. Michiel shows the BEST adaptation with the new colostomy if he shows which of the following?

  1. Look at the ostomy site
  2. Participate with the nurse in his daily ostomy care
  3. Ask for leaflets and contact numbers of ostomy support groups
  4. Talk about his ostomy openly to the nurse and friends

20) Arthur Cruz, a 45 year old artist, has recently had an abdominoperineal resection and colostomy. Mr. Cruz accuses the nurse of being uncomfortable during a dressing change, because his “wound looks terrible.” The nurse recognizes that the client is using the defense mechanism known as:

  1. Reaction Formation
  2. Sublimation
  3. Intellectualization
  4. Projection

21) Before discharge, the nurse scheduled the client who had a colostomy for colorectal cancer for discharge instruction about resuming activities. The nurse should plan to help the client understands that:

  1. After surgery, changes in activities must be made to accommodate for the physiologic changes caused by the operation.
  2. Most sports activities, except for swimming, can be resumed based on the client’s overall physical condition.
  3. With counseling and medical guidance, a near normal lifestyle, including complete sexual function is possible.
  4. Activities of daily living should be resumed as quickly as possible to avoid depression and further dependency.

22) The client who had transverse colostomy asks the nurse about the possible effect of the surgery on future sexual relationship. What would be the best nursing response?

  1. The surgery will temporarily decrease the client’s sexual impulses.
  2. Sexual relationships must be curtailed for several weeks.
  3. The partner should be told about the surgery before any sexual activity.
  4. The client will be able to resume normal sexual relationships.

23) The nurse plans to teach Michiel about colostomy irrigation. As the nurse prepares the materials needed, which of the following item indicates that the nurse needs further instruction?

  1. Plain NSS / Normal Saline
  2. K-Y Jelly
  3. Tap water
  4. Irrigation sleeve

24) A 58-year-old male client tells the office nurse that his wife does not let him change his colostomy bag himself. Which response by the nurse indicates as understanding of the situation?

  1. “Your wife’s need to help you is a reality you should accept”
  2. “Do you think your wife might benefit from counseling?”
  3. “You feel you need privacy when changing your colostomy?”
  4. “Have you discussed the situation with your doctor?”

25) Which of the following is TRUE in colostomy feeding?

  1. Hold the syringe 18 inches above the stoma and administer the feeding slowly
  2. Pour 30 ml of water before and after feeding administration
  3. Insert the ostomy feeding tube 1 inch towards the stoma
  4. A Pink stoma means that circulation towards the stoma is all well

26) A Client is scheduled to have a descending colostomy. He’s very anxious and has many questions regarding the surgical procedure, care of stoma, and lifestyle changes. It would be most appropriate for the nurse to make a referral to which member of the health care team?

  1. Social worker
  2. registered dietician
  3. occupational therapist
  4. enterostomal nurse therapist

27) A male client with bladder cancer has had the bladder removed and an ileal conduit created for urine diversion. While changing this client’s pouch, the nurse observes that the area around the stoma is red, weeping, and painful. What should nurse Katrina conclude?

  1. The skin wasn’t lubricated before the pouch was applied.
  2. The pouch faceplate doesn’t fit the stoma.
  3. A skin barrier was applied properly.
  4. Stoma dilation wasn’t performed.

28) When doing colostomy irrigation at home, a client with colostomy should be instructed to report to his physician :

  1. Abdominal cramps during fluid inflow
  2. Difficulty in inserting the irrigating tube
  3. Passage of flatus during expulsion of feces
  4. Inability to complete the procedure in half an hour

29) The first day after, surgery the nurse finds no measurable fecal drainage from a patient’s colostomy stoma. What is the most appropriate nursing intervention?

  1. Call the doctor immediately.
  2. Obtain an order to irrigate the stoma.
  3. Place the patient on bed rest and call the doctor.
  4. Continue the current plan of care.

30) The maximum height of irrigation solution for colostomy is

  1. 5 inches
  2. 12 inches
  3. 18 inches
  4. 24 inches

31) The nurse would know that dietary teaching had been effective for a client with colostomy when he states that he will eat:

  1. Food low in fiber so that there is less stool
  2. Everything he ate before the operation but will avoid those foods that cause gas
  3. Bland foods so that his intestines do not become irritated
  4. Soft foods that are more easily digested and absorbed by the large intestines

32) A temporary colostomy is performed on the client with colon cancer. The nurse is aware that the proximal end of a double barrel colostomy:

  1. Is the opening on the client’s left side
  2. Is the opening on the distal end on the client’s left side
  3. Is the opening on the client’s right side
  4. Is the opening on the distal right side

33) Which of the following behavior of the client indicates the best initial step in learning to care for his colostomy?

  1. Ask to defer colostomy care to another individual
  2. Promises he will begin to listen the next day
  3. Agrees to look at the colostomy
  4. States that colostomy care is the function of the nurse while he is in the hospital

34) While irrigating the client’s colostomy, Michiel suddenly complains of severe cramping. Initially, the nurse would

  1. Stop the irrigation by clamping the tube
  2. Slow down the irrigation
  3. Tell the client that cramping will subside and is normal
  4. Notify the physician
Answers and Rationales
  1. A. Brick Red. The stoma should be RED in color. Pale pink are common with anemic or dehydrated patients who lost a lot of blood after an operation. Blue stoma indicated cyanosis or alteration in perfusion. Stomas are not expected to be Gray.
  2. B. Stop the irrigation temporarily . If cramping occurs during a colostomy irrigation, the irrigation flow is stopped temporarily and the client is allowed to rest. Cramping may occur from an infusion that is too rapid or is causing too much pressure. The physician does not need to be notified. Increasing the height of the irrigation will cause further discomfort. Medicating the client for pain is not the appropriate action in this situation.
  3. A. destroys the odor-proof seal . Any hole, no matter how small, will destroy the odor-proof seal of a drainage bag. Removing the bag or unclamping it is the only appropriate method for relieving gas.
  4. B. Suspend the irrigant 45 cm above the stoma . 1 inches is equal to 2.54 cm. Convert the cm if you are not familiar. 45 cm is around 17 inches which is ideal for colostomy irrigation. Any value from 12 to 18 is accepted as the colostomy irrigant height. Tap water is used as an irrigant and is infused at room temperature. 4 cm is a little bit short for the ideal 3-4 inches. If cramping occurs STOP the irrigation and continue when is subsides.
  5. C. Loose, bloody . Normal bowel function and soft-formed stool usually do not occur until around the seventh day following surgery. The stool consistency is related to how much water is being absorbed.
  6. B. He has difficulty inserting the irrigation tube into the stoma . The patient should notify the doctor if he has difficulty inserting the irrigation tube into the stoma. Difficulty with insertion may indicate stenosis of the bowel. Abdominal cramping and expulsion of flatus may normally occur with irrigation. The procedure will often take an hour to complete.
  7. A. Increase fluid intake . To enhance effectiveness of the irrigation and fecal returns, the client is instructed to increase fluid intake and to take other measures to prevent constipation. Options B, C and D will not enhance the effectiveness of this procedure.
  8. A. When the client would have normally had a bowel movement . Irrigation should be performed at the time the client normally defecated before the colostomy to maintain continuity in lifestyle and usual bowel function/habit.
  9. A. solid. With a sigmoid colostomy, the feces are solid. With a descending colostomy, the feces are semi-mushy. With a transverse colostomy, the feces are mushy. With an ascending colostomy, the feces are fluid.
  10. B. Body image, disturbed . Body image, disturbed relates to loss of bowel control, the presence of a stoma, the release of fecal material onto the abdomen, the passage of flatus, odor, and the need for an appliance (external pouch). No data in the question support options A and C. Nutrition: less than body requirements, imbalanced is the more likely nursing diagnosis.
  11. C. Absence of gastrointestinal motility . This is primarily caused by the trauma of intestinal manipulation and the depressive effects anesthetics and analgesics.
  12. A. 3” . The nurse should insert the catheter no more than 3 inches.
  13. D. Protruding stoma with swollen appearance . A refers to a retracted stoma, B refers to a stoma that is getting a very poor blood supply. C is a description of stenosis of the stoma.
  14. C. Eat beet greens and parsley . Kinchay and Pechay helps lessen the odor of the colostomy. Spinach, broccoli, Cabbage, Cucumbers, Patola or bottle gourd also help lessen the odor BUT are gas formers. Eggs are not recommended because they are known to cause unpleasant odors in patients with colostomy.
  15. C. Hangs the bag on a clothes hook on the bathroom door during fluid insertion. The irrigation bag should be hung 12-18 inches above the level of the stoma; a clothes hook is too high which can create increase pressure and sudden intestinal distention and cause abdominal discomfort to the patient.
  16. B. Administer neomycin sulfate the evening before surgery 
  17. B. A difficult time accepting reality and is in a state of denial. As long as no one else confirms the presence of the stoma and the client does not need to adhere to a prescribed regimen, the client’s denial is supported
  18. B. 3-4 inches . Remember 3-4 inches. They are both used in the rectal tube and colostomy irrigation tube insertion. 1 to 2 inches is too short and may spill out the irrigant out of the stoma. Starting from 6 inches, it would be too long already and may perforate the bowel.
  19. B. Participate with the nurse in his daily ostomy care . Actual participation conveys positive acceptance and adjustment to the altered body image. Although looking at the ostomy site also conveys acceptance and adjustment, Participating with the nurse to his daily ostomy care is the BEST adaptation a client can make during the first few days after colostomy creation.
  20. D. Projection. Projection is the attribution of unacceptable feelings and emotions to others which may indicate the patients nonacceptance of his condition.
  21. C. With counseling and medical guidance, a near normal lifestyle, including complete sexual function is possible. There are few physical restraints on activity postoperatively, but the client may have emotional problems resulting from the body image changes.
  22. D. The client will be able to resume normal sexual relationships. Surgery on the bowel has no direct anatomic or physiologic effect on sexual performance. However, the nurse should encourage verbalization.
  23. A. Plain NSS / Normal Saline . The colon is not sterile, nor the stomach. Tap water is used in enema irrigation and not NSS. Although some clients would prefer a distilled, mineral or filtered water, NSS is not always necessary. KY Jelly is used as the lubricant for the irrigation tube and is inserted 3-4 inches into the colostomy pointing towards the RIGHT. Irrigation sleeve is use to direct the flow of the irrigated solution out of the stomach and into the bedpan or toilet.
  24. C. “You feel you need privacy when changing your colostomy?” 
  25. B. Pour 30 ml of water before and after feeding administration 
  26. D. enterostomal nurse therapist . An enterostomal nurse therapist is a registered nurse who has received advance education in an accredited program to care for clients with stomas. The enterostomal nurse therapist can assist with selection of an appropriate stoma site, teach about stoma care, and provide emotional support.
  27. B. The pouch faceplate doesn’t fit the stoma. If the pouch faceplate doesn’t fit the stoma properly, the skin around the stoma will be exposed to continuous urine flow from the stoma, causing excoriation and red, weeping, and painful skin. A lubricant shouldn’t be used because it would prevent the pouch from adhering to the skin. When properly applied, a skin barrier prevents skin excoriation. Stoma dilation isn’t performed with an ileal conduit, although it may be done with a colostomy if ordered.
  28. B. Difficulty in inserting the irrigating tube . Difficulty of inserting the irrigating tube indicates stenosis of the stoma and should be reported to the physician. Abdominal cramps and passage of flatus can be expected during colostomy irrigations. The procedure may take longer than half an hour.
  29. D. Continue the current plan of care. The colostomy may not function for 2 days or more (48 to 72 hours) after surgery. Therefore, the normal plan of care can be followed. Since no fecal drainage is expected for 48 to 72 hours after a colostomy (only mucous and serosanguineous), the doctor doesn’t have to be notified and the stoma shouldn’t be irrigated at this time.
  30. B. 12 inches ,  C. 18 inches . If you will answer in the CGFNS and NCLEX, C will be the correct answer. According to BRUNNER AND SUDDARTHS and Saunders, The height of the colostomy irrigation bag should be hanging above the clients shoulder at around 18 inches. According to MOSBY, 12 inches should be the maximum height. According to Lippinncots, 18 inches is the maximum height. According the the board of examiners, 12 inches should be the maximum height and an 18 inches irrigant height would cause rapid flow of the irrigant towards the colostomy. Therefore, answer in the local board should only be at 12 inches.
  31. B. Everything he ate before the operation but will avoid those foods that cause gas. There is no special diets for clients with colostomy. These clients can eat a regular diet. Only gas-forming foods that cause distention and discomfort should be avoided.
  32. C. Is the opening on the client’s right side . The proximal end of the double-barrel colostomy is the end toward the small intestines. This end is on the client’s right side. The distal end, as in answers A, B, and D, is on the client’s left side.
  33. C. Agrees to look at the colostomy. The client made the best initial step in learning to care for his colostomy once he looks at the site. This is the start of the client’s acceptance on his altered body image. A,B and D delays learning and shows the client’s disintrest regarding colostomy care.
  34. A. Stop the irrigation by clamping the tube . Stopping the irrigation will also stop the cramping and pain. During the first few days of irrigation, The client will feel pain and cramping as soon as the irirgant touches the bowel. This will start to lessen once the client got accustomed to colostomy irrigation. Slowing down the irrigation will not stop the pain. Telling the client that it is normal and will subside eventually is not acceptable when a client experiences pain. Pain is all encompasing and always a priority over anything else in most situations. Notifying the physician will not be helpful and unecessary.