The nurse is reviewing the client's medical record.

The nurse is assisting with the care the client prior to a blood transfusion

Which of the following actions should the nurse take? Select all that apply.

A) Use a moisturizing soap to clean the skin around the client's stoma:
Using a moisturizing soap is not recommended for cleaning the skin around the stoma. Moisturizing soaps can leave a residue that may interfere with the adhesion of the ostomy appliance. The skin around the stoma should be cleaned with warm water and mild soap that does not contain lotions, fragrances, or oils. This helps ensure the skin is clean and dry, promoting better adhesion of the skin barrier.

B) Create an opening on the skin barrier that is 1.27 cm (0.5 in) larger than the client's stoma:
The opening in the skin barrier should be about 1/8 inch (approximately 0.32 cm) larger than the stoma's diameter, not 1.27 cm (0.5 in) larger. A larger opening can cause the skin barrier to fit too loosely, leading to leakage and skin irritation. The skin barrier should fit snugly around the stoma to prevent any leakage and protect the surrounding skin.

C) Empty the client's ostomy pouch before removing the skin barrier:
It is essential to empty the ostomy pouch before removing the skin barrier to prevent fecal material from spilling or leaking during the appliance change. This helps maintain cleanliness, reduces the risk of skin irritation, and makes the procedure more comfortable for both the client and the nurse.

D) Change the client's ostomy appliance 1 hour after breakfast:
There is no specific time required after breakfast to change the ostomy appliance. The timing of appliance changes should be based on the client's individual needs and lifestyle, and it is more important to change the appliance when necessary (e.g., when the pouch is full or when the skin barrier is no longer intact) rather than adhering to a specific time after meals.

A) *Once you have completed a living will, it cannot be changed: This statement is inaccurate. A living will can be revised or updated at any time while the client is still capable of making decisions. The client can amend or revoke their living will if they change their mind about their wishes regarding end-of-life care or other medical decisions.

B) "You will need an attorney to appoint a health care surrogate": This statement is incorrect. While legal assistance might be beneficial in some cases, it is not required to appoint a health care surrogate. The appointment can typically be done through a simple form provided by the facility, and it is not necessary to hire an attorney for this process.



C) "You should appoint a family member as your health care surrogate": While appointing a family member as a health care surrogate is common, it is not a requirement. The person appointed should be someone who understands the client’s wishes and will act in the client's best interest. It is important to select someone who can make tough decisions, but it
doesn’t have to be a family member.

D) "Your health care surrogate will make decisions on your behalf if you are unable": This statement is correct. A health care surrogate is a person appointed to make medical decisions on behalf of the client if they are unable to do so themselves due to incapacity. This role is critical when the client cannot communicate their wishes due to illness or injury.