A nurse is preparing a client's body for a postmortem family viewing.

Which of the following actions should the nurse take?

Create an opening on the skin barrier that is 1.27 cm (0.5 in) larger than the client's stoma: It is important to ensure that the opening in the skin barrier is slightly larger than the stoma to prevent irritation or pressure on the stoma. This allows for proper fit and helps maintain a secure seal.

Use a mild, non-irritating soap or specifically designed ostomy cleanser to clean the skin around the client's stoma: Harsh soaps or cleansers can irritate the skin around the stoma. Using a moisturizing or gentle cleanser helps maintain the integrity of the skin and reduces the risk of irritation or breakdown.

Empty the client's ostomy pouch before removing the skin barrier: It is important to empty the ostomy pouch to prevent leakage or spillage during the appliance change. This helps maintain cleanliness and prevents potential contamination or soiling of the surrounding area.

The timing of the ostomy appliance change is not specified in the given options. The appropriate timing for changing the ostomy appliance depends on the individual client's needs and preferences. It may be helpful to consider factors such as the client's comfort, schedule, and amount of output in determining the best time for the appliance change. This instruction is not necessary for the teaching session.

A.The client's complaint of upper chest discomfort and coughing up thick clear sputum suggests a potential respiratory issue. Checking oxygen saturation is crucial to assess for possible respiratory distress or hypoxia.

B.Tremors are a chronic symptom associated with Parkinson's disease in this client. While monitoring tremors is important for assessing Parkinson's disease management, they are not an acute issue requiring immediate follow-up in this scenario.

C.Coughing up thick clear sputum and upper chest discomfort indicate potential respiratory distress or infection. Monitoring the respiratory rate helps assess the severity of respiratory distress or compromise.

D.Heart rate is a vital sign that can indicate cardiovascular status and response to the client's reported symptoms of feeling bad. Elevated heart rate may indicate stress, pain, or cardiac involvement.

E.The client is reported as alert and oriented to self. While changes in level of consciousness are always important to monitor, the client's current alert and oriented state suggests no immediate acute change.

F.Chronic health conditions such as Parkinson's disease and anxiety are part of the client's history but are not acute findings that require immediate follow-up compared to the acute symptoms of upper chest discomfort and respiratory distress reported.