Author Question: Because bowel contents from an ileostomy are virtually liquid, what should the nurse include in the ... (Read 37 times)

debasdf · **on:** Jul 11, 2018

Because bowel contents from an ileostomy are virtually liquid, what should the nurse include in the plan of care?

a. Evaluation and assessment of dietary intake of fiber
b. Evaluation and assessment of patient cleanliness
c. Evaluation and assessment of periostomal skin integrity
d. Evaluation and assessment of the adequacy of the collection device

Question 2

A 56 -year-old man is admitted to the emergency room with an acute attack of diverticulitis. The patient has a temperature of 102 F, and has an elevated white count. Which assessment would alert the nurse to impending septic shock?

a. Chest pain
b. Seizure
c. Tachycardia
d. Massive diarrhea

1_Step_At_ATime · **Reply #1 on:** Jul 11, 2018

Answer to Question 1

ANS: C
The nurse should assess the periostomal skin for impairment of integrity. The fecal material is liquid and has a potential for severe skin excoriation from the digestive enzymes.

Answer to Question 2

ANS: C
The patient with diverticulitis who has fever and an elevated white count has an infection that could lead to septic shock, which will present as tachycardia and hypotension.