Practice Question
The nurse is caring for a patient with a new ileostomy. What will the nurse’s top priorities for this patient be? (Select all that apply.)
Answer Choices:
Correct Answer:
Assessment of fluid volume status
Rationale:
Assessment of fluid volume status
💧 An ileostomy drains liquid stool rich in water and electrolytes, putting the patient at high risk for dehydration.
💧 Fluid loss through the stoma may reach 1–2 liters per day, especially in the early postoperative period.
💧 Monitoring for signs of volume depletion—such as tachycardia, dry mucous membranes, low urine output, hypotension—is a priority.
💧 Early fluid assessment helps prevent acute kidney injury, a complication common in new ileostomy patients with excessive output.
💧 Daily weights, intake/output tracking, and electrolyte monitoring are essential components of safe care.
Assessing the stoma for perfusion
❤️ The stoma must be checked frequently to ensure it is well-perfused, meaning healthy blood flow.
❤️ A normal stoma should appear moist, shiny, and red or pink.
❤️ Signs of compromised perfusion—such as dusky, pale, purple, or black coloring—signal ischemia or necrosis, which is a surgical emergency.
❤️ Early detection of perfusion problems ensures timely intervention to prevent stoma failure.
❤️ This is one of the highest priorities immediately after surgery because stoma viability determines long-term function.
Assess for skin breakdown around the stoma
🛡️ Ileostomy output contains digestive enzymes that are very irritating to the skin, leading to rapid breakdown if the skin is exposed.
🛡️ The nurse must check the peristomal skin for redness, erosion, ulceration, or leakage of stool under the appliance.
🛡️ Protecting the skin using proper pouch fitting, barrier films, and skin barriers prevents painful dermatitis and infections.
🛡️ Peristomal skin integrity is critical for patient comfort and long-term appliance adherence.
🛡️ Early detection of irritation promotes healing and reduces complications.
❌ Incorrect Answers
Change the patient’s diet to high residue
🚫 A high-residue diet (high-fiber foods like nuts, seeds, raw veggies) can cause blockages in a new ileostomy.
🚫 Patients with a new ileostomy require a low-fiber, low-residue diet initially to promote healing and prevent obstruction.
🚫 High-residue foods are reintroduced gradually over weeks to months depending on tolerance.
🚫 Therefore, this option is incorrect and unsafe for early post-operative ileostomy care.
Ambulating the patient once after surgery
🚶♂️ Encouraging mobility is important, but ambulating only once is inadequate and not a priority for ileostomy-specific risks.
🚶♂️ Patients should ambulate early and frequently, not just once, to prevent complications like ileus, DVT, and pneumonia.
🚶♂️ While activity is part of post-op care, it is not specific to ileostomy safety and not among the top priorities compared to fluid balance and stoma assessment.
🚫 Therefore, this answer does not meet the level of urgency needed for a new ileostomy patient.
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This question is from Examplify NR 325 SDAP Dynamic quiz 1 (Duplicate) which contains 16 questions.
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From Exam
Examplify NR 325 SDAP Dynamic quiz 1 (Duplicate)
16 Questions
View Full Exam Start PracticingQuestion Details
- Category: RN Nursing Exam(s)
- Subcategory: Examplify Exam(s)
- Domain: Medical-Surgical
- Answer Choices: 5