Upon assessment of the client 24 hours postprocedure for a hemicolectomy and temporary colostomy placement, the nurse notes that the client's stoma is dry and dark red in color. What would be the nurse's best action?
A. Notify the surgeon.
B. Document the finding as the only action.
C. Place a colostomy pouch system over the stoma.
D. Place petrolatum gauze dressing over the stoma.
A
The stoma should appear reddish pink and moist. If the stoma takes on a dark red or purple hue and becomes dry, firm, or flaccid, the stoma has signs of ischemia. The surgeon should be notified immediately.
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