The Wound Ostomy Continence Nursing Certification Board (WOCNCB) has been offering an advanced practice certification examination in ostomy care for more than 10 years. The examination validates competency of the APRN (Advanced Practice Registered Nurse) by testing analytical, critical thinking, and practice skills in ostomy management. Success on the examination is dependent upon mastery of entry-level ostomy knowledge and incorporation of more advanced skills such as prescribing medications and interpreting diagnostic testing.
Preparation for the WOCNCB Ostomy AP examination is essential. The Detailed Content Outline for the Ostomy AP examination provides a valuable study checklist. We recommend using the checklist to identify content areas you believe requires additional preparation. Begin with a thorough review of entry-level content, progressing to more complex advanced practice skills. The outline and APRN study references are found on the WOCNCB Web site. The WOCNCB has also developed a self-assessment examination for advanced practice certification in ostomy care. Like the questions in this article, each practice item has a detailed rationale, which can identify areas that need additional study.
1. A patient with an ileal pouch anal anastomosis exhibits symptoms of pouchitis for the first time 3 months after surgery to close the diverting ileostomy. Which medication would you prescribe/recommend?
- Amoxicillin/clavulanic acid
Content Outline: 4 C 1
Cognitive Level: Recall
Rationale: Antibiotic therapy is the primary treatment for patients with acute pouchitis, and the first line of therapy is metronidazole or ciprofloxacin although studies suggest that ciprofloxacin has a lower side effect incidence. Other antibiotics such as amoxicillin/clavulanic acid and sulfamethoxazole/trimethoprim may be used if the person is allergic to ciprofloxacin or there are contraindications to its use. Infliximab is a tumor necrosis factor-α inhibitor used to treat inflammatory bowel disease. This and other immunomodulators are being studied for treatment of chronic pouchitis, but antibiotics are the first choice of treatment for acute pouchitis.
2. A patient with rectal adenocarcinoma is having surgery and will have an ostomy. They have been told that the stoma may be temporary or permanent depending on the exact location of the tumor. The WOC-AP nurse is asked to do a site marking prior to surgery. Where would you mark this patient for a stoma?
- Right lower quadrant of the abdomen
- Left lower quadrant of the abdomen
- Right and left lower quadrants of the abdomen
- All 4 quadrants of the abdomen
Content Outline: 1 A 2
Cognitive Level: Application
Rationale: When performing a stoma site marking, the WOC-AP nurse should consider possible surgical options. A patient with rectal adenocarcinoma is a candidate for an abdominal perineal resection if the location of the tumor is too low to protect the anal sphincter during tumor resection. In this case, a permanent colostomy would be necessary and the stoma constructed in the left lower quadrant of the abdomen. If sphincter function can be preserved while completely resecting the tumor, a low anterior resection could be done, and a diverting loop ileostomy may be constructed to protect the anastomosis. This stoma is typically located in the right lower quadrant of the abdomen. Therefore, the WOC-AP nurse should mark 2 possible sites. One site marked in the right and left lower quadrants, and the surgeon would use the most appropriate site based on the type of stoma constructed.
3. An active 75-year-old woman with no chronic illnesses is seeking relief from intractable fecal incontinence secondary to neurogenic bowel. She finds the odor associated with this condition unacceptable. Which of the following solutions may be the best option for improving her quality of life?
- Odor-reducing skin cleansers
- Reusable padded underwear
- Diverting colostomy
- Dietary measures to improve stool consistency
Content Outline: 1 D, 4 1 (identify patient/family goals and factors affecting care)
Cognitive Level: Analysis
Rationale: A careful reading of the question stem will help when choosing the best answer. The stem informs us that the patient finds the odor of her fecal incontinence unacceptable, and the goal of treatment will be improving her quality of life. Bypassing the sphincter with a diverting colostomy will allow her to wear an odor-proof pouch over her stoma and relieve the embarrassment and anxiety of unpredictable bowel movements and need for immediate cleansing and clothing changes. Odor-reducing skin cleansers and reusable padded underwear are ways to manage fecal incontinence but still leave her with the problem of odor at each occurrence. Dietary measures to improve stool consistency can be effective in the management of diarrhea or constipation but do not correct the underlying neurological cause of her incontinence.
4. A patient with frequent pouch leakage has skin breakdown around their stoma. Which condition is most likely present?
- Irritant dermatitis
- Contact dermatitis
Content Outline: 2, B, 2 (diagnosis peristomal complications)
Cognitive Level: Recall
Rationale: Irritant dermatitis would be the correct answer choice because it is the most common peristomal skin condition. Peristomal moisture-associated skin damage is a type of irritant dermatitis caused by prolonged exposure to stomal effluent. The peristomal skin will exhibit erythema and, in many cases, superficial skin loss. The other answer options listed are less common peristomal skin complications but are still seen regularly by the ostomy nurse. Candidiasis is a fungal rash caused by a normal skin flora, Candida albicans, and can occur in persons who have received antibiotic treatment or are immunosuppressed. Allergic contact dermatitis results from hypersensitivity to a product used in the peristomal area. Folliculitis typically develops when hair follicle inflammation occurs due to injury or infection.
5. A patient with muscle invasive urothelial (bladder) cancer is scheduled for surgery. Which procedure would you expect them to have?
- Simple cystectomy
- ACE procedure
- Ileal vesicostomy
- Radical cystectomy
Content Outline: 4, A, 2, B (patient education surgical procedures)
Cognitive Level: Application
Rationale: Bladder cancer originates in the urothelium (lining) of the bladder. Higher-grade tumors can progress outward through the submucosa to the muscle and beyond to the perivesical fat, lymph nodes, and distant sites. Once bladder cancer invades the muscle, a radical cystectomy is recommended for those healthy enough to undergo major surgery. Simple cystectomy would not be the appropriate procedure in this case because only the bladder is removed. A radical cystectomy involves removing the bladder, surrounding fatty tissue, lymph glands, and pelvic organs such as the prostate and seminal vesicles in men or uterus and part of the vaginal wall in women. An ileal vesicostomy would not be a correct choice because it is performed for persons with neurogenic bladder dysfunction who are not able to perform clean intermittent self-catheterization. An ACE procedure is an antegrade colonic enema, performed to help the colon evacuate feces.
6. A patient who had treatment for prostate cancer 10 years ago presents with a several-month history of diarrhea and bright red blood from the rectum. A colonoscopy revealed 2 very small polyps. Dietary changes have made no difference in the frequency of diarrhea. What is the most likely diagnosis for this patient?
- Neuroendocrine tumor of the small intestine
- Radiation enteritis
- Large and extensive hemorrhoids
- Irritable bowel syndrome
Content Outline: 2, A, 1 (determine differential diagnosis)
Cognitive Level: Analysis
Rationale: The correct answer is radiation enteritis, a complication of radiation therapy used to treat pelvic malignancies of organs such as the prostate. This condition can occur as early as 2 weeks after treatment or as late as 30 years. Symptoms may include nausea, vomiting, pain, diarrhea, urgency, bleeding, or fecal incontinence. Hemorrhoids are a common cause of rectal bleeding, but a careful reading of the question stem helps eliminate this answer option because there was no mention of hemorrhoids in the stem in relation to the colonoscopy results. Irritable bowel syndrome (IBS) can be eliminated because, while diarrhea is a common symptom of IBS, bleeding is not. A neuroendocrine tumor of the small bowel may cause diarrhea and bleeding; however, these tumors are very rare and the only malignancy mentioned in the stem was prostate cancer.