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. Scrubs hands with antibacterial soap for 10 seconds: The recommended duration for effective handwashing is at least 20 seconds to ensure adequate removal of microbes and reduce infection risk. Washing for only 10 seconds is insufficient to properly cleanse the hands.

B. Washes his hands under hot running water: Using hot water can cause skin irritation and dryness, which may lead to compromised skin integrity. Warm or cold water is recommended as it effectively removes germs without damaging the skin.

C. Uses firm, circular motions to wash his hands: Using firm, circular motions ensures thorough cleansing of all hand surfaces, including between fingers and around nails. This technique promotes effective removal of dirt and microorganisms and is consistent with hand hygiene best practices.

D. Dries his hands from the forearms to the fingers: Drying should always proceed from the fingertips toward the forearms to prevent recontamination of clean hands. Drying from forearms to fingers can transfer contaminants back to the hands, defeating the purpose of handwashing.

A. An assistive personnel is late for the upcoming shift: Tardiness is an issue of staff performance or scheduling rather than client safety, and it should be addressed through administrative or managerial processes. It does not require an incident report unless it directly results in harm or neglect to a client.

B. A client refuses to eat at mealtime: Client refusal to eat is a common occurrence and is managed through nutritional assessments and care planning. While it should be documented in the medical record, it does not constitute an unusual or adverse event that requires an incident report.

C. A family member is napping in the client's room: A family member resting in the room is not an incident unless it interferes with care or violates facility policy. This situation is not associated with client harm or safety risk, so it does not meet the criteria for incident reporting.

D. A client's bed alarm is malfunctioning: A malfunctioning bed alarm is a safety issue, particularly for clients at risk of falls. It represents a potential hazard that could lead to client injury, making it necessary to complete an incident report to document the problem and prompt timely intervention or equipment repair.