Question

A nurse caring for a patient with a newly created ileostomy assesses the patient and notes that the patient has had no ostomy output for the past 12 hours. The patient also complains of worsening nausea. What is the nurses 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 to enhance motility.
D. Contact the physician and obtain a swab of the stoma for culture.

Answer 1

The nurse's priority action is to report signs and symptoms of obstruction to the physician.

Step-by-step explanation:

The nurse's priority action in this situation is B. Report signs and symptoms of obstruction to the physician. A newly created ileostomy should be producing output within a few hours after creation. The absence of ostomy output for 12 hours, combined with the patient's worsening nausea, suggests a possible obstruction, which requires immediate medical attention. The nurse should notify the physician so that appropriate interventions can be initiated, such as imaging studies or surgical intervention if necessary.