A nurse is caring for a client who is 4 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

A. Read the medication label twice prior to administration: Best practice requires reading the label three times (when retrieving, preparing, and before administering), so reading it only twice is insufficient for safety.

B. Ask the client if they have ever taken a similar medication: While helpful, this does not replace the need for the nurse to verify the medication's action, side effects, and interactions independently.

C. Use one patient identifier prior to medication administration: Safe practice requires using two patient identifiers (e.g., name and date of birth), so using only one is inadequate and unsafe.

D. Access the online drug formulary for an unfamiliar medication: This ensures the nurse understands the medication's purpose, dosage, side effects, and contraindications, which is critical for safe first-time administration.

A. "Empty the ostomy pouch when it becomes one-third full of contents.": It is important to empty the ostomy pouch when it is about one-third full to prevent leakage and pressure on the stoma. This helps avoid skin irritation and maintain comfort.

B. "Expect the stoma to turn a purple-blue color as it heals.": A stoma should be a reddish-pink color. A purple or blue color indicates poor circulation and may signal complications such as ischemia, which requires immediate attention.

C. "Cut the opening of the pouch an inch larger than the stoma.": The opening of the ostomy pouch should be cut about one-quarter to one-half inch larger than the stoma to prevent irritation or pressure on the stoma. This ensures a good fit and reduces risk of skin damage.

D. "Place a piece of gauze over the stoma while changing the pouch.": Placing gauze over the stoma during pouch changes protects the skin around the stoma fromcontact with stooland absorbs any drainage.

E. "Use povidone-iodine to clean around the stoma.": Povidone-iodine is too harsh for cleaning the stoma area and may cause skin irritation. The recommended cleaning solution is warm water and mild soap, followed by proper drying, to avoid skin damage and infection.