The nurse is caring for four clients.
The nurse should apply a warm thermal application to which client?

Choice A rationale

A purple or blue appearance of a stoma is a critical finding that indicates ischemia or total necrosis of the tissue. This suggests that the blood supply to the ileostomy has been compromised, which is a surgical emergency. A healthy stoma requires constant perfusion to remain viable. If the tissue is deprived of oxygenated blood, it will quickly die, leading to perforation or systemic infection. This requires immediate notification of the health care provider for intervention.

Choice B rationale

Slight edema is a common and expected finding in the immediate postoperative period after an ileostomy is created. The surgical trauma and manipulation of the bowel during the procedure cause localized inflammation and swelling. While the nurse should monitor the swelling to ensure it does not obstruct the stoma or interfere with the appliance fit, it is not an emergency that requires immediate reporting unless it is accompanied by other signs of vascular compromise or obstruction.

Choice C rationale

A moist and reddish-pink stoma is the ideal assessment finding and indicates that the stoma is healthy and well-perfused. This color signifies that the mucosal lining is receiving an adequate supply of oxygenated blood. The moisture indicates that the mucosal tissue is functioning correctly and is not becoming desiccated. This finding should be documented as a normal assessment and does not require any special notification to the health care provider or surgical team.

Choice D rationale

A small amount of blood during the cleaning of a stoma is usually normal because the intestinal mucosa is highly vascular and can be easily irritated by friction. As long as the bleeding is minimal and stops quickly after the cleaning process, it does not indicate a major complication. The nurse should use a gentle touch when performing stoma care. Heavy or persistent bleeding would be a concern, but small amounts are typically considered an expected clinical observation.

Choice A rationale

Removing a soiled dressing before washing hands and preparing the environment is a violation of infection control principles. The nurse's hands could be contaminated from other tasks, and touching a wound site without prior hygiene increases the risk of healthcare-associated infections. Furthermore, flushing the wound before having a clean field ready can lead to contamination of the surrounding area. The sequence must begin with hand hygiene and proper preparation of the sterile field to ensure safety.

Choice B rationale

Pouring the solution before washing hands or removing the old dressing is disorganized and risks contaminating the sterile solution. If the nurse pours the solution first, it sits exposed to the air while the contaminated dressing is handled, increasing the risk of airborne pathogens settling in the liquid. Hand hygiene must always be the very first step in any sterile or clean procedure to minimize the transfer of microorganisms from the nurse to the client or equipment.

Choice C rationale

The correct sequence begins with washing hands to reduce the microbial load on the nurse. Next, the nurse prepares the sterile field to ensure all necessary supplies are ready and uncontaminated. Applying clean gloves to remove the old, soiled dressing protects the nurse from pathogens in the wound drainage. After removal, the nurse discards the contaminated gloves and performs hand hygiene again before donning sterile gloves for the irrigation. This flow maintains the highest standard of surgical asepsis.

Choice D rationale

Preparing the sterile field and putting on sterile gloves before removing the soiled dressing is incorrect because the sterile gloves would become contaminated the moment they touch the old dressing. Removing a soiled dressing is a "clean" task, not a "sterile" one. Once the old dressing is gone and the area is cleaned, the nurse should then transition to sterile gloves for the actual irrigation and application of the new sterile dressing to prevent cross-contamination.