The client notices the ileostomy stoma is pinkish red and has small areas of bloody drainage. Which should the nurse use in client teaching? (Select all that apply.)
1. Stomas have many surface capillaries.
2. The nurse notifies the client's provider.
3. Report significant bleeding to provider.
4. This occurs with ineffective stoma care.
5. Prevent with a two-piece pouch system.
6. Healthy stomas are pinkish red and moist.
1, 3, 6
1, 3, and 6. The nurse instructs the client to expect a healthy stoma to be pinkish-red indicating adequate oxygenated blood flow. Because the stoma is vascular, the nurse also instructs the client to expect tiny drops of surface bleeding during stoma care because surface capillaries are fragile and rupture with surface cleansing.
2. Notifying the provider for tiny drops of surface bleeding is unnecessary because the nurse expects this finding; however, the nurse instructs the client to differentiate between surface bleeding and significant bleeding.
3. A pinkish-red stoma is consistent with clinical indicators for a healthy stoma with effective stoma care.
4. The pouch system is more likely to affect leakage and peristomal skin integrity than blood flow to the stoma.
You might also like to view...
A city that depended on tourist dollars had feedback that tourists were saying they were never returning because of the constant mosquito bites. Which of the following actions should be taken by the city?
a. Do not have any tourist events at dawn or dusk. b. Have everyone in town search for and remove any standing stagnant water. c. Give free bug repellent to each tourist. d. Tell tourists to avoid wearing bright colors.
Public health nurses use a common set of interventions to:
a. Describe the proper order of implementation. b. Emphasize surveillance as the main focus of public health practice. c. Guide practice and generate agency protocols. d. Improve the health status of communities, systems, individuals, and families.
The nurse would expect RhoGAM to be administered to which client?
1. A client at 28 weeks' gestation 2. A client undergoing kidney transplant 3. An HIV-positive client 4. An immunosuppressed client
When palpating the client's axillae, which of the following would be most appropriate?
A) Have the client hold the arm of the side being examined slightly away from the body. B) Tell the client to raise her arm on the side being examined up over her head. C) Hold the client's elbow of the side being examined with one hand. D) Have the client lean forward from the waist with arms outstretched.