A nurse is preparing to clean a blood spill on a bedside table.
Which of the following solutions should the nurse plan to use?

Choice A rationale

A small amount of liquid stool draining from the stoma is expected during the early postoperative period following colostomy placement. This indicates that the stoma is functioning and passing waste as intended.

Choice B rationale

The stoma protruding slightly from the abdomen, known as stoma protrusion or eversion, is a common and normal finding. It indicates that the stoma is correctly positioned and healing properly.

Choice C rationale

A dark-colored stoma is a concerning sign that indicates compromised blood flow to the stoma tissue, potentially leading to necrosis. This requires immediate medical attention to address the underlying cause and prevent further complications.

Choice D rationale

Light bleeding from the stoma when touched is normal in the immediate postoperative period. The stoma tissue is highly vascular, and minor bleeding is expected as it heals and forms new tissue connections.

Choice A rationale

Using a quick-release tie to secure the restraint is standard practice as it ensures the restraint can be removed quickly in case of an emergency, ensuring patient safety.

Choice B rationale

Tying the restraint to the bed frame is appropriate because it prevents the client from removing the restraint independently while still allowing for quick-release if necessary. It ensures the client's safety by securing the restraint to a stable part of the bed.

Choice C rationale

Placing the restraint across the client's chest requires intervention because it can restrict breathing and cause serious harm. This practice is unsafe and contraindicated in restraint use guidelines.

Choice D rationale

Applying the restraint over the client's gown is correct as it provides a barrier between the skin and the restraint, reducing the risk of skin irritation or injury.