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    Ati Rn Adult Medical Surgical 2023 Proctored Exam

    A nurse is providing discharge teaching for a client who had a partial colectomy 2 days ago. Which of the following information should the nurse include in the teaching?

    Explanation & Rationale

    Postoperative care following a partial colectomy with ostomy formation focuses on maintaining stoma function, preventing complications, and promoting patient independence in self-care. Clients must be educated on normal stoma appearance, pouch management, and expected return of bowel function. Proper ostomy care helps prevent leakage, skin breakdown, and infection. Nurses play a key role in reinforcing safe and practical self-management strategies before discharge. A. While notifying the provider about stoma color is important, a "dark red" stoma is actually a healthy finding. A healthy stoma should be moist and range in color from bright red to dark red. The nurse should instruct the client to notify the provider if the stoma becomes pale pink indicating anemia or purple/black indicating ischemia or necrosis, which is a surgical emergency. B. Placing an aspirin in the ostomy pouch to control odor is incorrect and unsafe because aspirin is not used for odor control and may cause chemical irritation or damage to the pouch system. Proper odor management includes dietary modifications and use of commercially available deodorizing agents designed for ostomy care. C. Emptying the ostomy pouch when it becomes one-third to halfway full is correct because it prevents excessive weight on the appliance, reduces the risk of leakage, and maintains a secure seal. Regular emptying also promotes comfort and helps protect the peristomal skin from breakdown due to prolonged contact with effluent. D. Stating that the ostomy should start functioning in five days is incorrect because bowel function typically returns within 24 to 72 hours after surgery, depending on the type of colectomy and anesthesia effects. Delayed output beyond expected timeframes may indicate complications such as ileus and should be reported.

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