A nurse is caring for a client who is scheduled for surgery.

Exhibit 1

Medical History

0800:

Client has a history of malnutrition, hyperlipidemia, and diabetes mellitus.

Mini Nutritional Assessment screening tool score of 7 points (0 to 14 points)

The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing? Select all that apply

A.Place the sterile field at the level of the nurse’s hips: This is not a recommended action. The sterile field should be placed at waist level or slightly above to ensure easy access and prevent contamination.

B. Hold bottles of sterile solution with the label in the palm of the hand: This protects the label from becoming wet and illegible, which is proper sterile technique.

C. Open the outermost flap of the sterile kit toward the body: When opening a sterile kit or package, the nurse should open the outermost flap away from the body to prevent contamination. Opening the flap toward the body increases the risk of airborne particles or contaminants from the nurse's clothing or skin entering the sterile field.

D. Sterile liquids should be poured into sterile containers on the sterile field, taking care not to contaminate the field.

A. "I will remove my antiembolic stockings while I am in bed": Antiembolic stockings, also known as compression stockings, are worn to prevent deep vein thrombosis (DVT) by promoting venous return. Removing them while in bed would compromise their effectiveness in preventing blood clots.

B. "I will perform ankle and knee exercises every hour."

Performing ankle and knee exercises every hour helps prevent complications such as muscle atrophy, contractures, and thromboembolism associated with immobility. These exercises promote circulation, maintain joint mobility, and prevent stiffness.

C. "I will hold my breath when rising from a sitting position": Holding one's breath while rising from a sitting position can increase intra-abdominal pressure and potentially cause dizziness or fainting. It is not a recommended practice and may lead to orthostatic hypotension.

D. "I will have my partner help me change positions every 4 hours": Changing positions every 4 hours is important for preventing pressure ulcers and promoting comfort, but it may not be frequent enough to prevent other adverse effects of immobility, such as joint stiffness and muscle weakness. Frequent position changes, at least every 2 hours, are recommended to maintain circulation and prevent complications.