A nurse is caring for a patient with a colostomy. The ostomy drainage bag should be emptied whenever it is
full.
1/2 full
1/4 full.
3/4 full.
The Correct Answer is B
The correct answer is Choice B.
Choice A rationale: Waiting until the ostomy drainage bag is full increases the risk of leakage and can put undue pressure on the stoma, leading to potential skin irritation or damage. Regular emptying is crucial for maintaining stoma health and preventing complications.
Choice B rationale: Emptying the ostomy drainage bag when it is 1/2 full is recommended to prevent leaks and reduce pressure on the stoma. This practice helps maintain skin integrity around the stoma and ensures the drainage bag functions effectively.
Choice C rationale: Emptying the ostomy drainage bag when it is only 1/4 full may be too frequent and unnecessary, leading to increased use of supplies and potential irritation from frequent manipulation. It is more practical to aim for 1/2 full for routine care.
Choice D rationale: Waiting until the ostomy drainage bag is 3/4 full increases the risk of leakage and pressure on the stoma, similar to waiting until it is full. It is essential to empty the bag more regularly to maintain optimal stoma health and prevent issues
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A The supine position is not suitable for administering an enema as it does not facilitate proper flow and retention of the solution.
Choice B High Fowler's position is not the best option for enema administration, as it might cause discomfort and hinder proper administration.
Choice C Semi Fowler's position is also not the best option for enema administration, as it may not allow the solution to flow effectively.
Choice D The Sims position, with the patient lying on the left side with the right knee flexed, allows the enema solution to flow downward by gravity and improves retention. It is the best position for enema administration.
Correct Answer is C
Explanation
Choice A For an ileostomy, liquid consistency of stool is expected as the output, and it is not an immediate concern.
Choice B Foul odor from the stool is common with ileostomy output, and while it can be unpleasant, it is not an immediate concern.
Choice C This finding should be reported immediately, as it could indicate bleeding from the stoma or intestinal mucosa, which requires prompt evaluation and intervention.
Choice D Continuous output from an ileostomy is normal and expected, so it is not a cause for immediate concern.
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