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 {"A":{"answers":"A,B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A,B"},"E":{"answers":"A,B"}}
Explanation
Side positioning can help with pain relief and prevent hypotension, which is beneficial for both maternal and fetal well-being. Urinary drainage (B) is typically a maternal intervention to manage the effects of epidural anesthesia on bladder function. Assisting with pushing efforts is a maternal intervention that supports the mother during the second stage of labor. Administering IV fluids is an intervention for the mother to maintain hydration and blood pressure, which indirectly benefits the fetus. Monitoring blood pressure is essential for both maternal and fetal health, as stable maternal blood pressure is critical for adequate fetal perfusion.
Correct Answer is B
Explanation
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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