A patient with a new ileostomy becomes dizzy when standing. The stoma output has increased greatly during the last shift, and the mucous membranes are dry. What should the nurse do first?
Correct answer: A. Assess vital signs and notify the nurse in charge promptly
- A. Assess vital signs and notify the nurse in charge promptly
- B. Ask the patient to walk slowly to improve circulation
- C. Restrict fluids until the stoma output decreases
- D. Give an antidiarrhoeal medicine without further assessment
Explanation
High ileostomy output with dizziness and dry mucous membranes suggests fluid and electrolyte loss. Vital signs help identify worsening hypovolaemia, and prompt escalation allows replacement to begin. Walking, restricting fluids, or giving medication without assessment may increase harm.
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About Clinical Judgement and Prioritisation
Clinical judgement links assessment findings, nursing knowledge and patient responses to a safe decision. Coverage includes ABCDE assessment, recognising actual or potential instability, prioritising airway, breathing and circulation, using urgency and risk rather than routine order, reassessing after intervention, and distinguishing a nursing priority from a medical diagnosis or a task that can wait.
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