A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object?

A. Temperature: A temperature of 38.3°C (101°F) indicates fever, which can signal a systemic inflammatory response or infection. In a client with a pressure injury that has developed purulent drainage and foul odor, fever raises concern for wound infection or possible systemic spread. This finding requires prompt provider notification for potential antibiotic therapy and further evaluation.

B. WBC count: A WBC count of 12,000/mm³ is elevated above the normal range and suggests an inflammatory or infectious process. In the context of a worsening pressure injury with purulent drainage, leukocytosis supports the possibility of an active infection. Reporting this finding allows the provider to consider diagnostic tests and treatment such as wound cultures or antimicrobial therapy.

C. Prealbumin level: The prealbumin level of 12 mg/dL is below the normal range, indicating poor nutritional status. Adequate protein and caloric intake are essential for wound healing and tissue regeneration. Low prealbumin can impair the healing of pressure injuries and may require nutritional intervention, supplementation, or referral to a dietitian.

D. Hemoglobin level: The hemoglobin level of 13 g/dL falls within the normal reference range for adults. Adequate hemoglobin supports oxygen delivery to tissues, which is important for wound healing. Because this value is within normal limits, it does not require reporting as an abnormal finding.

E. Blood pressure: The blood pressure reading of 128/64 mm Hg is within an acceptable range and does not indicate hemodynamic instability. There are no signs of hypotension or hypertension that would compromise tissue perfusion or indicate acute deterioration. Therefore, this value does not require immediate reporting.

F. Pain level: The client’s pain has increased from 2/10 on Day 1 to 6/10 on Day 4, indicating worsening discomfort. Increasing pain in a pressure injury may signal infection, tissue deterioration, or inflammation. This change in pain level should be reported because it represents a significant clinical change requiring reassessment of wound management and pain control.

G. Odor of wound: A foul odor from a pressure injury is commonly associated with bacterial infection or necrotic tissue. When combined with purulent drainage and yellow wound tissue, it strongly suggests wound deterioration and possible infection. This finding should be reported promptly for evaluation and potential treatment adjustments.

H. Bowel sounds: Active bowel sounds in all four quadrants indicate normal gastrointestinal motility. This is a normal assessment finding and is unrelated to the client’s pressure injury status. Because it does not represent a complication or abnormal change, it does not need to be reported to the provider.

A. Suction the client's airway: Airway suctioning is indicated when there are signs of airway obstruction such as gurgling sounds, visible secretions, ineffective coughing, or decreased oxygen saturation due to mucus accumulation. Without evidence of secretion retention, suctioning is invasive and not the most immediate or least restrictive intervention.

B. Instruct the client to perform incentive spirometry every hour: Incentive spirometry promotes alveolar expansion, prevents atelectasis, and improves lung ventilation in postoperative or immobilized clients. However, it is primarily a preventive and long-term respiratory intervention rather than an immediate measure for acute dyspnea.

C. Humidify the client's supplemental oxygen: Humidification is helpful for clients receiving prolonged oxygen therapy to prevent mucosal dryness and irritation of the respiratory tract. While it improves comfort and secretion management over time, it does not provide immediate relief for acute breathing difficulty. Therefore, it is not the priority action.

D. Assist the client to an upright position: Positioning is a rapid, noninvasive intervention that improves lung expansion and diaphragmatic movement. Sitting the client upright (such as in Fowler’s or high-Fowler’s position) decreases pressure from abdominal organs on the diaphragm and enhances ventilation. This quickly improves oxygenation and is the priority action for a client experiencing dyspnea while lying supine.