A nurse is caring for a patient who is scheduled for a surgical procedure. The nurse is reviewing the patient’s electronic medical record.
Which of the following findings places the patient at risk for a surgical complication? Select all that apply.

Choice A rationale
Locking the wheels on the patient’s bed is a safety measure that should be taken to prevent the bed from moving during the transfer.
Choice B rationale
Positioning the chair at a 90-degree angle to the bed could make the transfer more difficult. It’s usually recommended to position the chair parallel to the bed.
Choice C rationale
Elevating the patient’s bed isn’t typically necessary for a transfer and could potentially make the transfer more difficult.
Choice D rationale
Placing the chair on the patient’s left side, the side of the patient’s weakness, could make the transfer more difficult. It’s usually recommended to lead with the patient’s stronger side.

Choice A rationale
Initiating life-saving measures such as a rapid response call would not be appropriate in this context. The patient is in a hospice setting, which focuses on providing comfort and quality of life for patients who are nearing the end of life, rather than aggressive life-saving interventions.
Choice B rationale
Calling the provider because these signs and symptoms are abnormal would not be the correct response. In a hospice setting, these symptoms are expected and are indicative of the natural dying process.
Choice C rationale
The statement that rapid respirations that are unusually deep and regular are curative for the patient is incorrect. Cheyne-Stokes respirations, characterized by a pattern of increasing and then decreasing depth of breath followed by a period of apnea, are often seen in patients nearing the end of life. They are not curative but are a sign of the body’s decreasing metabolic demands and changing physiology as death approaches.
Choice D rationale
The nurse understanding that these are impending signs of death and are normal is the correct response. The symptoms described, including loss of appetite, swelling of the limbs, increased sleep, Cheyne-Stokes respirations, and hallucinations, are all common in the final stages of life.
Recognizing these signs can help the nurse provide appropriate care and support to the patient and their family during this time.