A nurse is caring for a client who has a spinal cord injury.

Nurses' Notes 0600:

Adventitious lung sounds auscultated in lower lobes bilaterally. Spirometry encouraged. Cough productive for clear sputum.

1000:

Cough productive for clear sputum following incentive spirometry and coughing exercises. Face and neck flushed. Client reports headache.

Abdomen distended. Last bowel movement was 2 days ago with hard stool. Provider Prescriptions

Nifedipine 30 mg PO for blood pressure greater than 150/100 mm Hg and notify provider Acetaminophen 650 mg PO q4 hr PRN pain

For each potential nursing action, click to specify if the action is anticipated or contraindicated for the client.

Choice A rationale:

Applying sterile gloves when changing the ostomy pouch is essential for infection control. However, this is a standard practice and not specific to the client's condition. While important, it is not the priority instruction for a client with a new ostomy.

Choice B rationale:

Notifying the provider if the stoma becomes pink and moist is crucial information for the client. A pink and moist stoma indicates good blood supply and healing, while changes in color or moisture might indicate complications. This instruction is essential for the client's ongoing care and to prevent potential complications, making choice B the correct answer.

Choice C rationale:

Emptying the ostomy pouch when it is half full is a general guideline to prevent leakage and maintain hygiene.

Choice D rationale:

Soaps with lotions or perfumes may interfere with the pouch seal or cause peristomal skin irritation. Rinse and dry well.

Choice C rationale:

Recommending scrambled eggs is appropriate for a client with dysphagia caused by a stroke. Scrambled eggs have a soft and moist texture, making them easier to swallow for individuals with difficulty swallowing. It is crucial to choose foods that are easy to chew and swallow, as well as foods that can be easily moistened with sauces or gravies to aid in swallowing.

Choice A rationale:

Crispy rice bars are dry and hard, posing a significant risk for individuals with dysphagia. Foods that are dry, crunchy, or crumbly can be difficult to swallow and may lead to choking, especially for individuals with impaired swallowing abilities. Therefore, crispy rice bars are not a suitable choice for a client with dysphagia.

Choice B rationale:

Peanut butter, especially when consumed without added moisture or in large amounts, can be thick and sticky, making it challenging to swallow, especially for individuals with dysphagia. It can adhere to the walls of the throat, causing discomfort and difficulty in swallowing. While peanut butter can be a good source of protein, it is not an ideal choice for someone with swallowing difficulties.

Choice D rationale:

Soda crackers are dry and can be crumbly, making them a poor