You are providing care for a patient who had an ileostomy placed one week ago after a bowel resection. You note the following findings during your assessment (see chart below):

Stoma Assessment	Stoma is protruding 2cm, is red and moist. Peristomal area is clean and intact.
Output	Liquid stool that is malodorous. Gas present in the appliance.
General Status	Patient is avoiding looking at the ileostomy during care.
Laboratory Data	Potassium 3.6 mEq/L (normal 3.5 to 5 mEq/L) Sodium 137 mEq/L (normal 135 to 145 mEq/L) Creatinine 0.9 mg/dL (normal 0.6 to 1.2 mg/dL)

What finding is most concerning to the nurse?

A. Call for assistance. While calling for help may be necessary if the patient becomes unresponsive or falls, the priority action is to ensure their safety immediately by helping them sit down.

B. Assist the patient in sitting down on the bed. The patient is experiencing dizziness upon standing, which could indicate orthostatic hypotension or another condition. The best immediate action is to help them sit down to prevent a fall or further complications.

C. Assess the vital signs for orthostatic hypotension. While assessing for orthostatic hypotension is important, it should be done after ensuring the patient is safe by sitting them down.

D. Notify the provider. The provider may need to be informed if the dizziness persists or if there is an underlying medical issue. Still, immediate intervention (sitting the patient down) takes priority before notifying the provider.

A. Ensure the patient is safe and leave to get them some water: The provider’s verbal statement is not an official order. The student nurse must ensure a written order is in place before implementing dietary changes.

B. Contact dietary to order the patient a full liquid meal: The student nurse cannot place orders. They must first verify that the provider has documented the order.

C. Request that the provider write the order in the chart: Orders must be documented in the patient’s medical record before they can be carried out. The student nurse should ensure the provider formally writes the order.

D. Record the information in the patient chart: The student nurse cannot chart an order that has not been officially written by the provider.