Which of the following nursing actions is most important to include in the plan of care for a client who had an abdominal-perineal resection the previous day?
A)Teach about a low-residue diet.
B)Monitor output from the stoma.
C)Assess the perineal drainage and incision.
D)Encourage acceptance of the colostomy stoma.

Question

Quizplus · Accepted Answer

Because the perineal wound is at high risk for infection, the initial care is focused on assessment and care of this wound. Teaching about diet is best done closer to discharge from the hospital. There will be very little drainage into the colostomy until peristalsis returns. The client will be encouraged to assist with the colostomy, but this is not the highest priority in the immediate postoperative period.

Which of the Following Nursing Actions Is Most Important to Include