Difficulty: Medium
Average Score: 70%
Simulated
The client is 6 days postÔÇötotal proctocolectomy with ileostomy creation for ulcerative colitis. The clientÔÇÖs ileostomy is draining large amounts of liquid stool, and the client has dizziness with ambulation. Which parameters should the nurse assess immediately?
Correct answer
A, B, C, E
Rationale
The nurse should assess for increasing pulse rate over time because it is a sign of dehydration; large amounts of ileostomy output can result in dehydration, and the dizziness with ambulation could be from dehydration. B. The nurse should assess for decreasing urine output because it is a sign of dehydration; large amounts of ileostomy output can result in dehydration, and the dizziness with ambulation could be from dehydration. C. The nurse should assess for decreasing weight because it is a sign of dehydration; large amounts of ileostomy output can result in dehydration, and the dizziness with ambulation could be from dehydration. D. The ability to move the lower extremities is not related to dehydration. E. The nurse should assess the temperature readings because a low-grade temperature is a sign of dehydration; large amounts of ileostomy output can result in dehydration, and the dizziness with ambulation could be from dehydration.