The nurse is caring for an anxious patient who is scheduled for surgery for colostomy placement. While the nurse is talking to the patient, the patient states, "I am so scared." It is a priority for the nurse to focus on addressing the

The correct answer is Choice A.

Choice A rationale: A pale blue stoma indicates compromised perfusion or necrosis. This is a surgical emergency requiring immediate assessment to prevent tissue death and systemic complications.

Choice B rationale: Continuous drainage may reflect normal output depending on stoma type. It’s not immediately life-threatening and doesn’t require urgent intervention.

Choice C rationale: Fecal contamination is expected with colostomies. While hygiene is important, this does not indicate a critical issue needing priority care.

Choice D rationale: A beefy red, moist stoma is the expected healthy appearance of a functioning colostomy. No intervention is needed.

Choice A The supine position is not suitable for administering an enema as it does not facilitate proper flow and retention of the solution.

Choice B High Fowler's position is not the best option for enema administration, as it might cause discomfort and hinder proper administration.

Choice C Semi Fowler's position is also not the best option for enema administration, as it may not allow the solution to flow effectively.

Choice D The Sims position, with the patient lying on the left side with the right knee flexed, allows the enema solution to flow downward by gravity and improves retention. It is the best position for enema administration.