The nurse assesses an adult client 24 hours after a bowel exploration and formation of a sigmoid colostomy. Which assessment finding should be reported to the surgeon immediately?

Choice A reason: Rubbing painful areas gently may provide temporary relief, but it is not a specific or effective long-term management strategy for Raynaud's disease. This advice could lead to further discomfort if not done correctly, and it does not address the primary trigger, which is cold exposure.

Choice B reason: Enrolling in a pain clinic can provide pain relief alternatives, but this is a general recommendation and not specific to the management of Raynaud's disease. While pain clinics can be helpful for chronic pain management, practical daily interventions are also crucial for this condition.

Choice C reason: Wearing gloves when handling cold items is a direct and practical way to prevent painful spasms associated with Raynaud's disease. This condition is characterized by episodes of reduced blood flow to the extremities, typically triggered by cold temperatures. By wearing gloves, the client can protect their hands from cold exposure, which helps prevent these painful spasms.

Choice D reason: Return appointments for IV pain medication are not typical for managing Raynaud's disease. Pain management for Raynaud's generally focuses on preventive measures and lifestyle adjustments to avoid triggers, rather than relying on IV medications for pain relief.

Rationale for Correct Choices

Option 1: Impaired gas exchange is the priority problem because the client's oxygen saturation is critically low at 88%, and the assessment reveals expiratory wheezes, rapid respirations (28/min), and severe shortness of breath. These indicate difficulty in maintaining adequate oxygenation.

Option 2: "I used my rescue inhaler three times, but I couldn’t catch my breath." This statement directly indicates that the asthma attack is unresponsive to the usual medication, highlighting the severity of the impaired gas exchange.

Rationale for Incorrect Choices

Option 1:

A. Anxiety: While anxiety may be present, it is a secondary issue caused by the asthma attack and is not the root cause of the client’s symptoms.

C. Ineffective airway clearance: Although wheezing suggests partial obstruction, the critical issue is the impaired oxygenation and low oxygen saturation rather than mucus or secretions obstructing the airway.

D. Activity intolerance: The client’s difficulty breathing is not primarily due to exertion but rather to the asthma attack itself.

Option 2:

A. "I was jogging when it started.": This identifies the trigger for the attack but does not explain the severity or lack of response to medication.

C. "My symptoms are worse when outdoors and when exercising.": This is helpful for identifying long-term triggers but does not prioritize the immediate issue of unrelieved shortness of breath.

D. "I noticed my inhaler was expired and was worried the medication was not working.": While this points to a lapse in medication management, it does not address the acute respiratory distress.