The ostomy nurse reviews follow-up findings after ileostomy surgery. Which findings require follow-up? Highlight the findings that suggest impaired stoma perfusion, skin injury, dehydration, or obstruction.
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Choose your responses, then check the answer.
Explanation
Follow up on a dusky stoma, persistent leakage with burning skin, high watery output with dizziness, and absent output with cramping and vomiting. A healthy stoma is moist and red, and the surrounding skin should remain protected.
Quick answer The concerning findings are a dusky purple stoma, persistent leakage with painful wet skin, 1,500 mL of watery output with dizziness, and no output with cramping and vomiting. These patterns suggest perfusion, skin, fluid, or obstruction complications.
Why this is correct A healthy stoma is normally moist and pink to red because it is well perfused. Dark or dusky color can indicate reduced blood flow. Effluent under the barrier damages peristomal skin, high ileostomy output can cause dehydration and electrolyte loss, and absent output with pain or vomiting can indicate obstruction.[2]
Easy analogy or mental picture Think of the stoma as a living outlet with four checks: color for blood flow, seal for skin protection, output for fluid balance, and flow for patency. The checklist helps organize assessment but does not set one universal output limit for every client.
Memory hook Color, skin, volume, flow: a change in any lane deserves a closer look.
NCLEX decision rule In ostomy care, distinguish normal mucosal features from a new threat. Moist red tissue and slight contact bleeding can be expected, but dark color, persistent skin exposure, symptomatic high output, or obstructive symptoms require follow-up.
Why the other choices are wrong A moist red stoma, slight contact bleeding, emptying the pouch before it becomes heavy, intact dry peristomal skin, and a closely fitted barrier are expected or protective findings in the displayed record.
References
[1]
NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing
[2]
UOAA: Nursing Care After Ostomy SurgeryUnited Ostomy Associations of America
[3]
WOCN: Basic Ostomy Skin CareWound, Ostomy and Continence Nurses Society