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. Assault.

Assault is the threat or apprehension of harmful or offensive contact. In this scenario, the nurse is making a threat to administer medication by injection if the client doesn't comply with swallowing pills. Even though the nurse hasn't physically carried out the action yet, the threat itself constitutes assault. The client feels threatened by the nurse's statement, creating apprehension of harm or offensive contact.

B. Defamation: Defamation involves making false statements that harm a person's reputation. There is no indication of defamation in this scenario.

C. Battery: Battery involves the intentional and unauthorized touching of another person. While administering medication by injection without consent could be considered battery, the nurse has only made a threat at this point, not carried out the action.

D. Invasion of privacy: Invasion of privacy involves intruding into someone's private affairs without permission. There is no indication of invasion of privacy in this scenario.

A. Urinary catheter care:

While urinary catheter care is important for maintaining urinary hygiene and preventing urinary tract infections, it is not as urgent as addressing respiratory needs. If the client is stable and not experiencing acute urinary retention or other urinary complications requiring immediate intervention, urinary catheter care can be performed after addressing respiratory concerns.

B. Wound irrigation:

Wound irrigation is typically performed to clean and debride wounds, promoting healing and preventing infection. While wound care is essential for preventing complications, it is not as urgent as ensuring adequate respiratory function, particularly in a client with an artificial airway requiring suctioning.

C. Enteral feeding:

Enteral feeding is crucial for providing nutrition to clients who cannot consume adequate nutrients orally. However, initiating enteral feeding can wait until the client's respiratory needs are addressed, as the immediate priority is to ensure effective breathing and oxygenation.

D. Endotracheal suctioning

Endotracheal suctioning is a critical procedure performed to clear secretions from the airway, ensuring adequate oxygenation and ventilation in patients with artificial airways such as endotracheal tubes. Maintaining a patent airway is a fundamental aspect of patient care, and suctioning helps prevent airway obstruction, hypoxia, and respiratory distress. Therefore, it takes precedence over other procedures in ensuring the client's respiratory stability and preventing potential complications.