Practice Question
A nurse is assisting with caring for a female client who has a newly placed ileostomy.
Answer Choices:
Rationale:
1️⃣ Color of the stoma
🌡️Why first? A stoma should normally be moist, red to pink, indicating healthy blood supply. A dark purple color suggests compromised circulation or ischemia, which is a surgical emergency.
🌡️Blistering around the stoma may indicate skin trauma or irritation, but the priority is to assess and act on signs of poor perfusion because untreated ischemia can lead to stoma necrosis.
🌡️Immediate action: Notify the surgeon or stoma nurse specialist promptly to evaluate blood flow to the stoma. Early recognition may save the stoma and prevent severe complications.
🌡️This aligns with the ABC approach—compromised perfusion is addressed before less urgent issues.
2️⃣ Ostomy pouch seal 🩹
🌡️After confirming and addressing the stoma’s vascular status, the next priority is fixing the leaking pouch seal.
🌡️Why important? Leakage of stool onto the peristomal skin quickly causes skin breakdown due to the caustic nature of ileostomy effluent (rich in digestive enzymes).
🌡️Stool contact also increases the risk of infection and further blistering.
🌡️The pouch should be emptied when it is one-third to one-half full, and in this case, it is three-fourths full, which can worsen leakage and compromise the seal.
🌡️Replacing or reinforcing the wafer and ensuring a proper fit prevents further leakage and protects skin integrity.
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This question is from PN Fundamentals Online Practice 2023 A which contains 104 questions.
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Question Details
- Category: LPN Nursing Exam(s)
- Subcategory: LPN ATI Exams
- Domain: Fundamentals of Nursing
- Answer Choices: 0