A nurse is evaluating a client's acceptance of having a new ileostomy.
Which of the following statements by the client indicates acceptance?

Choice A rationale:

Establish learning outcomes. Establishing learning outcomes is an important step in developing an education program, but it should not be the first step. Before setting learning outcomes, the nurse should assess the participants' needs and abilities, which includes determining their literacy level. Without this information, it is difficult to create meaningful and relevant learning outcomes.

Choice B rationale:

Create handouts for participants. Creating handouts is an essential part of the education program, but it should come after determining the literacy level of participants. Handouts should be tailored to the participants' literacy levels to ensure that they can understand and benefit from the materials provided.

Choice D rationale:

Schedule a time to implement the program. Scheduling a time to implement the program is also an important step, but it should not be the first action taken. Before scheduling, the nurse needs to gather information about the participants' needs and abilities to ensure that the program is appropriately designed and timed for their convenience.

Choice C rationale:

Determine the literacy level of participants. Determining the literacy level of participants should be the first action taken when developing an education program for older adults. This step is crucial because it helps the nurse understand the participants' reading and comprehension abilities. It allows the nurse to tailor the program materials and teaching methods to match the literacy level of the group. Older adults may have varying levels of literacy, and customizing the program to their needs will improve its effectiveness and ensure that participants can fully engage and benefit from the educational content.

Choice A rationale:

Pedal pulses are a measure of peripheral circulation. A 2+ rating is considered normal, indicating a brisk, expected response. There’s no change in the client’s pedal pulses from Day 1 to Day 5, so this doesn’t require immediate follow-up.

Choice B rationale:

Oxygen saturation is not mentioned in the Nurses’ Notes, so we cannot provide a rationale for this choice.

Choice C rationale:

Breath sounds are an important indicator of respiratory health. The client’s breath sounds are clear and present throughout on both Day 1 and Day 5, which is normal and doesn’t require immediate follow-up.

Choice D rationale:

Respiratory rate is not mentioned in the Nurses’ Notes, but any significant change in respiratory rate could indicate a problem such as infection or pain, and would require immediate follow-up.

Choice E rationale:

The abdominal dressing shows a large amount of serosanguinous drainage on Day 5, compared to a small amount on Day 1. This could indicate a complication such as infection or dehiscence (separation of the wound), especially since the client reported feeling something “popped” at the incision site after coughing. This requires immediate follow-up.

Choice F rationale:

Heart rate is not mentioned in the Nurses’ Notes, but any significant change in heart rate could indicate a systemic response to factors such as pain or infection, and would require immediate follow-up. In summary, while pedal pulses and breath sounds remain normal, the change in the abdominal dressing and potential changes in respiratory rate and heart rate (though not documented here) should be addressed immediately to ensure the client’s health and recovery.