A nurse is caring for a client.

Exhibits

A nurse is reviewing a client's medical record. Select the 3 findings that place the client at risk for hearing impairment.

A. Apply friction when drying the client's skin. Friction can damage the skin, especially in clients with incontinence who are at risk for skin breakdown.

B. Use soap to clean the client's skin. Soap can be drying and irritating to the skin. pH-balanced cleansers are preferred to maintain skin integrity.

C. Apply a barrier cream to the client's skin. Barrier creams protect the skin from moisture, reducing the risk of skin breakdown and irritation from incontinence.

D. Use hot water to clean the client's skin. Hot water can dry out and damage the skin. Warm water should be used instead to gently clean the skin.

A. The skin around the stoma is red: Redness around the stoma may indicate skin irritation, which is common but typically managed with proper skin care and is not always an urgent concern. However, if the redness is severe or associated with other symptoms, it should be monitored. Reporting may be necessary if it worsens.

B. The ostomy is draining frequently: Frequent drainage may be expected depending on the location of the colostomy and the client’s diet. While it should be monitored, frequent drainage alone does not necessarily indicate a problem that needs to be reported.

C. The stool is yellow-green: The color of stool can vary depending on diet, the location of the colostomy, and bile presence. Yellow-green stool is often expected in higher colostomies and may not need to be reported unless it is a sudden change.

D. The stoma is pale in color: A pale or dusky stoma can indicate compromised blood flow, which is a serious concern and should be reported to the provider immediately. A healthy stoma should be pink or red.