A nurse is planning care for a client who is 8 hr postoperative following a coronary artery bypass grafting. Which of the following assessments should the nurse plan to perform first?

Rationale:

A. Provide the client with high-protein meals: High-protein meals are important for tissue repair and healing, especially in clients at risk for pressure ulcers. Adequate nutrition, including protein, is essential to promote skin integrity and prevent further skin breakdown.

B. Gently massage the reddened areas: Massaging reddened areas can increase tissue damage and worsen skin breakdown. Instead of massaging, the nurse should relieve pressure on those areas to prevent further injury.

C. Place the client in a supine position: The supine position might increase pressure on the client's scapulae. It is better to reposition the client to relieve pressure from affected areas, ideally by turning them to their side or using pillows to offload pressure.

D. Use hot water when cleaning the client's skin: Hot water can dry and irritate the skin, worsening the condition. The nurse should use lukewarm water and gentle, non-irritating products to clean the skin and prevent further damage.

Rationale:

A. "I will use a mirror to inspect my feet daily." People with diabetes are at risk for nerve damage, which can lead to unnoticed foot injuries or infections. Using a mirror helps to inspect the feet daily and thoroughly, especially the soles, to prevent complications.

B. "I will eat a low residue diet." A low residue diet is not recommended for diabetes management. The focus for diabetic clients should be on balanced nutrition that controls blood glucose levels rather than restricting residue unless there are gastrointestinal issues.

C. "I will take my insulin 30 minutes before exercise." Taking insulin 30 minutes before exercise could increase the risk of hypoglycemia, especially if the exercise is vigorous. It is generally recommended to adjust insulin doses or carbohydrate intake depending on the type and intensity of the exercise, under the guidance of a healthcare provider.

D. "I will limit my fluid intake to 1 liter daily." Diabetes management does not involve limiting fluid intake unless there is a specific contraindication, such as kidney disease or heart failure. Adequate hydration is important for managing blood sugar levels and preventing dehydration.