After d.s. is settled into his room, the NGT and IV line are functioning well, and he receives pain medication, you begin your admission assessment
His abdomen is extremely large, firm to touch, with multiple scars and an ileostomy pouching system in his right lower quadrant (RLQ).
Describe the common complications of an ileostomy.
Mechanical obstruction: Blockage can occur when food becomes lodged within the intestine or
from adhesions or peristomal breakdown. Patients with ileostomies are instructed to chew food
thoroughly, be careful of certain kinds of high-fiber foods, and remain well hydrated. D.S. has a
history of fistula and multiple abdominal surgeries that place him at increased risk for mechanical
obstruction or obstruction because of strictures or scar tissue.
Dehydration: The small intestines excrete up to 3 L of fluid and enzymes per day. Without a colon to
reabsorb the majority of the fluid and electrolytes, the patient can easily become dehydrated and
suffer electrolyte imbalance. Certain foods such as sugars, fats, and spices can stimulate the bowel
and exaggerate the fluid loss.
Skin breakdown: Peristomal breakdown can result from mechanical, chemical, allergic, or infectious
insults.
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A student is elated at having completed the NCLEX-PN® and now eagerly awaits the results of the exam. The student will receive the results of the exam from
A) the school of nursing where the student attended the exam. B) the National Council of State Boards of Nursing (NCSBN). C) the state board of nursing. D) the test center where the student wrote the NCLEX-PN®.
A patient in diabetic ketoacidosis is very lethargic and has a "funny" odor to his breath. The nurse would suspect this to be a result of
a. alcohol intoxication. c. hyperphosphatemia. b. hyperglycemia. d. acetone.
A client tells the nurse "I'm told that I should reduce the stress in my life, but I have no idea where
to start.". The best suggestion for the nurse to make would be a. "Why not start by learning to meditate? That technique will cover everything.". b. "In cases like yours, physical exercise works to elevate mood and reduce anxiety.". c. "Most stress is related to conflicts in interpersonal relationships. You can work on becoming more assertive.". d. "Keeping a journal can help you identify sources of stress by looking at activities that put a strain on energy or time or trigger anger or anxiety.".
When discontinuing an IV, the nurse will:
1. remove the dressing, remove the catheter, dispose of the used equipment in the "sharps" container, and chart observations and actions. 2. observe the site for redness, swelling, and pain and put on sterile gloves. Remove the dressing catheter and chart findings and action. 3. observe the site for redness, swelling, and pain and put on clean gloves. Remove the dressing and catheter, place a 2 ? 2 dressing over the site, and chart findings and action. 4. observe the site for redness, swelling, and pain and put on clean gloves. Remove the dressing and catheter; chart findings and action.