A nurse is caring for a client who is postoperative. Which of the following actions should the nurse take to help prevent an incisional infection?

Choice A reason: Documenting the pulse as "82/min, client sitting in a chair" is correct and shows an understanding of the teaching. The pulse rate is within the normal range for a resting adult, which is typically between 60 to 100 beats per minute. Additionally, noting the client's position is important as body position can affect pulse rate; sitting can slightly increase the pulse compared to lying down.

Choice B reason: The temperature of "36.9°C (98.4°F)" is within the normal range for body temperature, which is typically between 36.5°C to 37.5°C (97.7°F to 99.5°F). Documenting the temperature in both Celsius and Fahrenheit is a good practice, as it provides clarity and prevents confusion in clinical settings where different systems may be used.

Choice C reason: The documentation of respirations as "auscultated, even at 22/min, client supine" is appropriate. The normal respiratory rate for a healthy adult at rest is between 12 to 20 breaths per minute. Noting that the respirations are even and the client's position is supine is important, as different positions can affect breathing patterns and rates.

Choice D reason: A blood pressure reading of "108/68 mm Hg" falls within the normal range, which is generally considered to be between 90/60 mm Hg and 120/80 mm Hg for adults. Proper documentation of blood pressure includes both systolic and diastolic values, as seen here, which is essential for accurate monitoring and treatment decisions.

Choice A reason: Putting on sterile gloves is not necessary before palpating the abdomen. Sterile gloves are typically used for procedures that require an aseptic technique, such as inserting a catheter or performing a surgical procedure. Palpation of the abdomen is a non-sterile procedure, and clean gloves are usually sufficient to prevent the transmission of microorganisms.

Choice B reason: Elevating the client's head is not a standard preparatory step before palpating the abdomen. While it may be necessary to adjust the client's position for comfort or to assess certain areas, the head elevation is not specifically related to the palpation process. The client should be in a supine position with knees slightly bent to relax the abdominal muscles, which facilitates palpation.

Choice C reason: Percussion of all four quadrants is part of the abdominal assessment but is not the step that precedes palpation. Percussion is used to assess the size and density of abdominal organs, detect the presence of fluid or gas, and evaluate tenderness. However, the correct sequence of abdominal assessment is inspection, auscultation, percussion, and then palpation.

Choice D reason: Auscultating bowel sounds is the correct action before palpating the abdomen. This is because palpation can alter bowel motility, which may change the sounds heard. Auscultation should be performed after inspection and before percussion and palpation to obtain an accurate assessment of bowel activity. Normal bowel sounds range from 5 to 30 per minute and are characterized by clicks and gurgles.