A nurse caring for a patient with a newly created ileostomy assesses the patient and notes that the patient has had not ostomy output for the past 12 hours. The patient also complains of worsening nausea. What is the nurse's priority action?
A) Facilitate a referral to the wound-ostomy-continence (WOC) nurse.
B) Report signs and symptoms of obstruction to the physician.
C) Encourage the patient to mobilize in order to enhance motility.
D) Contact the physician and obtain a swab of the stoma for culture.
Ans: B
Feedback:
It is important to report nausea and abdominal distention, which may indicate intestinal obstruction. This requires prompt medical intervention. Referral to the WOC nurse is not an appropriate short-term response, since medical treatment is necessary. Physical mobility will not normally resolve an obstruction. There is no need to collect a culture from the stoma, because infection is unrelated to this problem.
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