A nurse is collecting data from a client who has a newly placed colostomy.
Which of the following findings should indicate to the nurse the client has accepted their new altered body image?

Choice A rationale

A small amount of dark red wound drainage, such as 20 mL over 4 hours, is a typical postoperative finding in clients following bowel surgery. This observation indicates normal postoperative healing and does not require immediate intervention, making it a lower priority.

Choice B rationale

Pain at the incision site rated as 6 out of 10 is a moderate pain level that is expected in the postoperative period. While managing pain is important, this is not an urgent priority compared to other clinical findings that indicate systemic compromise or potential complications.

Choice C rationale

Dark yellow urine output totaling 60 mL over 4 hours reflects low urine output but does not meet the oliguria threshold of less than 30 mL per hour. This finding may require further assessment but is not immediately critical compared to symptoms of altered consciousness.

Choice D rationale

A client arousing easily but quickly falling back asleep indicates a potential alteration in consciousness, which can result from hypovolemia, hypoxia, or other complications. This finding is a priority for reporting as it may signify deteriorating neurological or hemodynamic status that requires immediate intervention. .

Choice A rationale

An oropharyngeal airway is used for maintaining an open airway in unconscious clients but is unnecessary for oropharyngeal suctioning. It does not aid in clearing secretions and could obstruct the suctioning procedure if incorrectly positioned.

Choice B rationale

Water-soluble lubricant is not required for oropharyngeal suctioning, as it is typically performed without introducing external lubrication. Using lubricant could increase the risk of aspiration and interfere with the suction catheter's effectiveness in clearing secretions.

Choice C rationale

Sterile gloves are commonly used in invasive procedures to maintain sterility, but oropharyngeal suctioning at home is generally considered a clean procedure. Non-sterile gloves suffice, prioritizing practicality without significantly increasing the risk of infection.

Choice D rationale

A Yankauer catheter is specifically designed for oropharyngeal suctioning, as its rigid shape and large lumen are effective in clearing thick oral secretions. Its ergonomic design allows safe and efficient use in both clinical and home settings to maintain a clear airway.