A nurse is reinforcing discharge teaching with the family of an older adult client about safety precautions when administering a hypotonic enema to the client. Which of the following instructions should the nurse include in the teaching?

Choice A Reason:

"I will no longer be able to eat nuts." While it's essential to be cautious about certain foods after a colostomy, avoiding nuts altogether may not be necessary. The client should discuss dietary restrictions with their healthcare provider or a registered dietitian.

Choice B Reason:

"I will empty the pouch every 2 to 3 hours." The frequency of pouch emptying can vary depending on the client's individual needs and the ostomy type. There's no fixed schedule for emptying the pouch, so this statement is not necessarily accurate.

Choice C Reason:

"I should expect my stool to be formed." The consistency of stool from a colostomy can vary depending on the location of the stoma and the type of colostomy. It may be formed or semi-formed, but it can also be more liquid or loose, depending on the circumstances. The client should

Choice D Reason:

"I will notify my doctor if the stoma starts to look purple." This statement reflects the client's awareness of the importance of monitoring the stoma's color and seeking medical attention if it appears discolored or compromised. A purple or dark-colored stoma can indicate inadequate blood supply, which is a concern that should be addressed promptly.

discuss stool consistency with their healthcare provider.

Choice A Reason:

Document objective findings about the situation is incorrect. While documentation is important, it should not be the first action when the charge nurse suspects a colleague is under the influence of alcohol. Patient safety takes precedence, and immediate action to remove the nurse from patient care is necessary to prevent potential harm.

Choice B Reason;

Assigning clients to the remaining staff is incorrect. Assigning clients to other staff members is an appropriate step but should come after the nurse under suspicion has been removed from patient care to ensure their safety. Patient safety is the primary concern.

Choice C Reason:

Calling the supervisor to ask for another nurse is incorrect. Contacting the supervisor is a reasonable action, but it should be done after the immediate safety concern has been addressed by removing the nurse from patient care. This allows the supervisor to be informed of the situation and take appropriate action.

Choice D Reason:

Removing the nurse from the client care area is correct.When a charge nurse detects the smell of alcohol on a nurse's breath, the first and most immediate action should be to remove the nurse from the client care area to ensure patient safety. Alcohol impairment can severely compromise a nurse's ability to provide safe and effective care. Once the nurse is removed from patient care, further actions, such as documenting objective findings and contacting the supervisor, can be taken to address the situation and ensure appropriate follow-up, including any necessary interventions or investigations. Patient safety should always be the top priority in such situations.