The nurse is caring for a patient who suffered a gunshot wou…

The nurse is caring for a patient who suffered a gunshot wound to the abdomen.  The nurse notes the following vital signs: T 97.9 F (Temporal), P 126 and irregular, R 26 and shallow, BP 82/48, and O2 sat 86% on 12 L/min via a non-rebreathing mask.  The nurse is unable to assess pain due to the patient being unconscious. What is the nurse’s primary concern with this patient?

The nurse is providing ileostomy care and notes the followin…

The nurse is providing ileostomy care and notes the following: pale stoma, collecting pouch filled with greenish liquid stool and large amount of flatus, and a reddened area under the adhesive of the appliance. Which assessment finding should the nurse report immediately?