A nurse is contributing to the plan of care for a client who has AIDS and has malnutrition. Which of the following actions should the nurse include in the plan of care?

Choice A Reason:
Preparing the sterile dressing supplies 30 min before the dressing change is correct. While it's crucial to have all supplies ready before starting the procedure, preparing them 30 minutes in advance might not align with the principles of maintaining sterility. It's generally best to prepare sterile supplies just before the procedure to minimize the risk of contamination.
Choice B Reason:
Don sterile gloves before removing the dressing is incorrect. Sterile gloves should indeed be worn during the dressing change, but they should be put on after removing the old dressing. This ensures that the clean gloves don't touch potentially contaminated surfaces during the removal of the old dressing.
Choice C Reason:
Disinfect the wound bed with alcohol before applying tape is incorrect. Using alcohol to disinfect the wound bed is not recommended as it can cause tissue irritation and delay wound healing. Sterile saline or another wound cleansing solution prescribed for wound care would be more appropriate to clean the wound bed. Additionally, applying tape directly to the wound is generally avoided to prevent further damage to the fragile tissues of a pressure ulcer.
Choice D Reason:
Offering the client pain medication before the procedure is correct. Providing pain medication before the procedure ensures the client's comfort and helps manage any discomfort or pain associated with the dressing change, particularly when dealing with a stage III pressure ulcer, which can be quite sensitive.

Choice A Reason:

Passing of flatus is correct. Passing flatus (gas) is an encouraging sign that the digestive system is functioning and that gas is moving through the colostomy. This is a positive indicator of colostomy function.

Choice B Reason:

Stoma is pinkish-red. A pinkish-red stoma indicates good blood circulation to the area, which is vital for the health of the stoma tissue. A healthy-colored stoma is a positive sign.

Choice C Reason:

Tolerating a clear liquid diet. Tolerating a clear liquid diet might be an indicator of gastrointestinal function, but it might not specifically confirm the functionality of the colostomy itself.

D. Absent bowel sounds

Absent bowel sounds might be present immediately postoperatively due to the effects of anesthesia and abdominal surgery. However, bowel sounds aren't a direct indicator of colostomy function.