Assessment findings for a client following a colectomy for familial polyposis include an ileostomy bag that contains a large amount of fecal liquid and an IV infusion of dextrose 5% in lactated Ringer's infusing at a rate of 100 mL/hour. Which assessment is most
Urinary output.
Serum electrolytes.
Peristomal skin integrity.
Skin turgor.
The Correct Answer is B
A. While monitoring urinary output is important, it is not the most critical assessment in this context.
B. Monitoring serum electrolytes is crucial because the large amount of fecal liquid output from the ileostomy can lead to significant electrolyte imbalances.
C. Peristomal skin integrity is important but is secondary to the immediate risk of electrolyte imbalances.
D. Skin turgor is important for assessing hydration status, but monitoring electrolytes is more directly related to the immediate postoperative care.
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Related Questions
Correct Answer is C
Explanation
A. Normalized electrolytes are important but do not specifically indicate gastrointestinal motility.
B. Decreased nausea can be a sign of improvement but is less specific than passing flatus.
C. Passing flatus indicates that there is movement of gas through the intestines, which is a direct sign of returning gastrointestinal motility.
D. Return of appetite can occur for various reasons and is not as direct an indicator of GI motility as passing flatus.
Correct Answer is D
Explanation
A: Osmolality measures the concentration of solutes in the blood and is not typically affected by naproxen or indicative of the reported symptoms.
B: While naproxen can cause gastrointestinal irritation and ulceration, it does not typically affect serum calcium levels. Monitoring serum calcium would not directly address the client's reported symptoms.
C: ESR is a nonspecific marker of inflammation and is not directly related to the reported symptoms of stomach pain, weakness, and fatigue associated with naproxen use.
D: Naproxen, a nonsteroidal anti-inflammatory drug (NSAID), can cause gastrointestinal bleeding, which may lead to anemia and a decrease in hemoglobin levels. Monitoring hemoglobin levels can help assess for gastrointestinal bleeding in this client who is experiencing stomach pain and weakness/fatigue.
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