A nurse is preparing to administer an enema to a client.
Which of the following actions should the nurse plan to take?

Findings that require follow-up:

1. Refuses to look at the stoma:
   • This indicates the client is experiencing emotional or psychological distress related to the ileostomy. It may hinder his ability to learn and participate in self-care, which is crucial for managing the ileostomy effectively.
2. Expresses no interest in learning about stoma care:
   • Lack of interest in learning about stoma care suggests the client is not prepared or willing to take responsibility for his own care, which can lead to complications and poor outcomes. Education and support are needed to help the client become more comfortable and knowledgeable about managing the ileostomy.
3. The skin surrounding the stoma is reddened and has small open areas:
   • This indicates irritation or infection of the skin around the stoma, which requires prompt attention to prevent further complications and ensure proper healing. It may be necessary to review the client's stoma care routine and make adjustments to prevent skin breakdown.
4. During cleaning, a small amount of bleeding was noted from the stoma:
   • Bleeding from the stoma can be a sign of trauma, infection, or other issues that need to be addressed. Prompt evaluation and intervention are necessary to identify the cause and prevent further complications.

Findings that do not require follow-up:

1. The client's abdomen is soft and nondistended:
   • This is a normal finding, indicating that there is no abdominal distention or rigidity, which could be signs of underlying issues such as bowel obstruction or peritonitis.
2. The stoma is red and is draining brown liquid stool:
   • A red stoma with brown liquid stool is generally a normal finding, as the stoma should be red or pink in color and the stool consistency can vary based on the type of ileostomy and the client's diet.
3. The client appears alert and oriented to person, place, and time:
   • This indicates the client is mentally alert and aware of his surroundings, which is a positive sign of overall cognitive function and well-being.
4. The ileostomy pouch was changed:
   • Changing the ileostomy pouch is a routine part of stoma care and does not indicate any issues that require follow-up unless there are problems noted during the process, such as skin irritation or pouch leakage.

Choice A rationale

It is best practice to use a new cotton swab for each swipe to avoid contamination. Each area should be cleaned with a separate cotton swab.

Choice B rationale

Oil-based lubricants should not be used with catheters as they can interfere with the material of the catheter. Water-based lubricants are preferred.

Choice C rationale

Testing the balloon on the indwelling urinary catheter before insertion can lead to an increased risk of contamination and potential damage to the catheter.

Choice D rationale

Sterile gloves are essential to prevent infection during the insertion of an indwelling urinary catheter. Maintaining a sterile field is crucial.