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    HESI RN Exit VI Proctored Exam

    A client with a history of inflammatory bowel disease develops severe ulcerative colitis and is admitted to the intensive care unit after surgery for a fistula repair. Which intervention is most important for the nurse to include in the plan of care?

    Explanation & Rationale

    A. Fluid replacement is crucial to prevent dehydration and maintain electrolyte balance, which is vital in clients with severe ulcerative colitis and after surgery.B. Turning the client is important to prevent pressure ulcers but is not as immediately critical as fluid balance.C. Recording wound drainage is necessary but secondary to ensuring the client’s fluid and electrolyte status.D. Assessing skin condition is important but fluid balance takes priority in this scenario.

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