The nurse is caring for a patient who had a colostomy placed 5 days earlier. The nurse notes that the stoma is red and moist. Which action should the nurse take?
a. Notify the physician immediately.
b. Apply pressure.
c. Note the condition of the stoma in her notes.
d. Change the appliance pouch.
C
The stoma should be red or pink and moist. After assessment the nurse will note the appearance of the stoma in the patient HER. If it is gray, purple, or black, report this to the charge nurse or physician immediately. Pressure is applied to control active bleeding. The information given in the question does not indicate that there is a need to change the appliance at this time.
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