A nurse in an acute mental health care facility is prioritizing care for multiple clients.
Which of the following clients should the nurse see first?

Choice A rationale:

Applying skin sealant on damp skin is not a correct technique when changing an ostomy appliance. Skin should be clean and thoroughly dry before applying any ostomy products. Moisture on the skin can interfere with the adhesion of the pouching system, leading to skin irritation and leakage.

Choice B rationale:

Removing the appliance before emptying the pouch is not the correct technique. Ostomy pouches are designed to be emptied without removing the entire appliance. Removing the pouch unnecessarily can cause discomfort to the client and may damage the surrounding skin. Regular emptying of the pouch while leaving the appliance in place is the appropriate practice.

Choice C rationale:

Ensuring that the skin is slightly damp for better adhesion of the pouch is not accurate. Ostomy pouches adhere best to clean, dry skin. Moisture on the skin can compromise the adhesive seal and lead to skin irritation. Therefore, the skin should be thoroughly dried before applying the ostomy pouching system.

Choice D rationale:

Tracing the size of the stoma onto the skin barrier is the correct technique when changing an ostomy appliance. The opening of the skin barrier (wafer) should match the size and shape of the stoma to ensure a proper fit. Tracing the stoma's size onto the barrier helps in cutting the opening to the appropriate size, preventing leakage and ensuring a secure fit around the stoma.

Choice A rationale:

Placing the client's hands in warm water is a method to stimulate urination and is appropriate for clients experiencing difficulty voiding. However, in this situation, the client is postpartum and unable to urinate, which might indicate a potential issue with the bladder or urethra. Performing a fundal massage would be more appropriate in this case as it helps to stimulate uterine contractions, which can aid in the expulsion of clots or retained placental fragments, potentially relieving the obstruction and allowing the client to urinate.

Choice B rationale:

Performing a fundal massage is the correct choice in this scenario. The nurse should gently massage the client's uterine fundus to promote uterine contractions. This can help expel clots or retained placental fragments, relieving any obstruction in the urethra and allowing the client to urinate. It's a standard practice after childbirth to prevent postpartum hemorrhage and ensure the uterus contracts properly.

Choice C rationale:

Administering a benzodiazepine is not appropriate for this situation. Benzodiazepines are a class of medications primarily used for anxiety, insomnia, and seizures. There is no indication for the use of benzodiazepines in this case, as the client's inability to urinate is likely related to a physiological issue postpartum, not anxiety or seizures.

Choice D rationale:

Placing an ice pack on the client's perineum is not the correct intervention for this situation. Ice packs on the perineum are typically used to reduce swelling and relieve pain after childbirth. However, the client's inability to urinate suggests a potential issue within the urinary system, and a fundal massage to promote uterine contractions would be more appropriate.