A nurse is preparing to assess a client’s carotid arteries. Which of the following actions should the nurse plan to take?

Choice A Reason:

The requirement that the client speaks the same language as the nurse is not a standard criterion for informed consent. While effective communication is crucial, the presence of an interpreter can facilitate understanding if there is a language barrier. The nurse’s signature does not confirm the language spoken by the client.

Choice B Reason:

The nurse’s signature on the informed consent form confirms that the client signed the document in the nurse’s presence. This is a standard practice to ensure that the consent was given voluntarily and that the client was present at the time of signing. It helps in verifying the authenticity of the consent.

Choice C Reason:

The nurse’s signature also confirms that the client was not coerced into signing the consent form. Informed consent must be given voluntarily, without any form of pressure or coercion. This ensures that the client’s decision is made freely and with full understanding of the procedure or treatment.

Choice D Reason:

The nurse’s signature confirms that the client has the legal authority to give consent. This means that the client is of legal age and has the mental capacity to understand the information provided and make an informed decision. It is essential to ensure that the client is legally competent to consent to the treatment or procedure.

Choice E Reason:

The requirement that the client does not have a mental health condition is not a standard criterion for informed consent. Clients with mental health conditions can still provide informed consent if they have the capacity to understand the information and make a decision. The nurse’s signature does not confirm the mental health status of the client.

Choice A Reason:

Cutting the opening of the pouch 1/8 inch larger than the stoma is crucial to ensure a proper fit and to prevent skin irritation. The stoma can change size, especially in the initial weeks post-surgery, so it is important to measure it regularly and adjust the pouch opening accordingly. This practice helps in maintaining a secure seal and protecting the skin around the stoma from exposure to waste.

Choice B Reason:

Placing a piece of gauze over the stoma while changing the pouch can help in absorbing any output and keeping the area clean during the change. However, this is more of a practical tip rather than a strict instruction for ostomy care. It is not essential for all patients and may vary based on individual preferences and needs.

Choice C Reason:

Expecting the stoma to turn a purple-blue color as it heals is incorrect. A healthy stoma should be pink or red and moist. A purple-blue color can indicate poor blood supply or other complications and should be reported to a healthcare provider immediately. Proper stoma care includes monitoring its color and seeking medical advice if any unusual changes occur.

Choice D Reason:

Using povidone-iodine to clean around the stoma is not recommended. The skin around the stoma should be cleaned with mild soap and water or just water. Povidone-iodine can be too harsh and may cause irritation or allergic reactions. It is important to use gentle cleaning methods to maintain skin integrity and prevent complications.

Choice E Reason:

Emptying the ostomy pouch when it becomes one-third full of contents is a standard practice to prevent leaks and maintain comfort. Overfilling the pouch can lead to detachment from the skin and potential skin irritation. Regular emptying helps in managing the ostomy effectively and maintaining hygiene.