hard · NCLEX-RN basic-care
During a home health visit, the nurse finds a client with a 2-week-old ileostomy has a BP of 88/50 mm Hg and is lethargic. The client’s spouse says the 'pouch has been full of water' for 2 days.
Which action is the priority?
- Teach the spouse about the signs of high-fiber food blockages
- Call emergency services for immediate medical transport
- Change the ostomy pouching system to a high-output bag
- Administer an 8 oz glass of water and recheck the BP in 1 hour
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