A nurse is assisting in the care of a client who is scheduled for an appendectomy.

Exhibits

The nurse is assisting with preparing the client for surgery. Select the 3 findings that require follow-up prior to surgery.

A. Interlock their fingers and hold their hands away from their body above their waist: This position maintains the sterility of the gloves by keeping the hands visible and above waist level, which is the accepted sterile field boundary.

B. Keep their arms at the sides of their body with their hands in a relaxed position: Keeping hands close to the body or at the sides risks contamination because the hands might touch nonsterile surfaces or the body, which is outside the sterile field.

C. Place one hand over the other against the part of the gown covering their upper body: Touching the gown, which is considered sterile only in the front above the waist, can risk contamination if hands move unexpectedly or if the gown surface is touched by nonsterile areas.

D. Clasp their hands together in a relaxed position behind their body at their waist: Positioning hands behind the back limits visibility and control over the sterile field, increasing the risk of contamination by touching nonsterile surfaces or moving out of the sterile boundary.

A. Dietary intake: The client ate toast at 0600 and experienced vomiting. Since general anesthesia is typically used for an appendectomy, recent food intake increases the risk of aspiration and should be reported immediately to the surgical team.

B. Pain level: The client reports increasing pain (now 8/10) with rebound tenderness. This may indicate worsening inflammation or risk of rupture, which requires reassessment and potentially expedited surgical intervention.

C. Blood pressure: The blood pressure of 124/80 mm Hg is within normal limits and does not require follow-up before surgery. It reflects stable hemodynamics.

D. Informed consent: The provider has already obtained informed consent and placed it in the medical record. No further follow-up is needed unless the client withdraws consent or shows signs of confusion.

E. Oxygen saturation: The client's oxygen saturation is 96% on room air, which is acceptable. There are no indications of respiratory compromise that require further intervention preoperatively.

F. Allergies: The client reports allergies to shellfish, latex, and penicillin. These pose serious risks during surgery (e.g., anaphylaxis to latex gloves or antibiotics) and must be addressed in the preoperative checklist to ensure appropriate substitutes are used.