# A nurse is assessing a client who is 8 hours post-op following an ileostomy creation. Which finding requires immediate follow-up?

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> url: https://mymerci.kr/pages/nclex_q.php?qn_id=505795&lang=en  
> language: en  
> subject: Basic Care and Comfort  
> category: BCC

## Question

A nurse is assessing a client who is 8 hours post-op following an ileostomy creation. Which finding requires immediate follow-up?

History

Vitals

Labs

Orders

Notes

Client underwent ileostomy creation 8 hours ago for ulcerative colitis. No known allergies. Past medical history unremarkable.

BP 118/72, HR 88, RR 16, Temp 98.8°F (37.1°C), SpO2 98% on room air

Hgb 11.2 g/dL, WBC 9,500/mm³

Vital signs every 4 hours, stoma assessment every 4 hours, advance diet as tolerated, pain management per protocol

Client is drowsy but arousable. Abdomen soft, bowel sounds hypoactive. Stoma appears dusky and purplish with dry surface. No frank bleeding. Dressing has small amount of serosanguineous drainage.

1

Moist, red stoma with slight edema

✕

2

Dusky, purplish stoma with dry surface

✕

3

Small amount of serosanguineous drainage on dressing

✕

4

Client reports mild incisional pain rated 3/10

✕

## Explanation

A viable new stoma should be moist and red to pink. A dusky, purplish, or dry stoma suggests impaired blood flow and possible ischemia, which requires immediate evaluation. A moist, red stoma with slight edema is a normal postoperative finding. A small amount of serosanguineous drainage is expected in the early postoperative period. Mild incisional pain rated 3/10 is common after surgery and does not indicate an emergency.

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