A nurse is preparing to assist a client out of bed to a wheelchair following left knee surgery. The nurse should identify that which of the following images indicates the correct placement of the wheelchair?

Target 1: Paralytic ileus

• The client is 6 hours postoperative with hypoactive bowel sounds and no mention of flatus or stool. The use of IV opioids (morphine) increases the risk for reduced gastrointestinal motility. Paralytic ileus is common after abdominal surgery and with opioid use.

Target 2: Atelectasis

• The client has shallow bilateral breath sounds postoperatively, which indicates a risk for atelectasis, a common complication due to decreased mobility, pain limiting deep breathing, and effects of anesthesia.

Rationale for Incorrect Choices:

• Urinary tract infection: The client voided 350 mL of clear yellow urine after catheter removal with no signs of infection.
• Delayed wound healing: No signs of infection or poor wound healing; the dressing is dry and intact.
• Deep vein thrombosis: Though a risk postoperatively, the client is wearing SCDs and has even pedal pulses with no edema, lowering immediate concern.

A. Syringe: A syringe is essential for irrigating a stage 4 pressure injury to cleanse the wound thoroughly without causing trauma to the tissue. Proper irrigation helps remove debris and bacteria, promoting healing. A syringe allows controlled, gentle flushing of the wound bed, which is important in managing deep, complex wounds like stage 4 pressure injuries.

B. Tongue depressor: A tongue depressor is generally used to examine the throat and oral cavity and is not suitable for wound care. It lacks the precision and safety needed for wound cleaning or dressing application, especially for deep pressure ulcers.

C. Adhesive tape: Adhesive tape is used to secure dressings but is not a primary supply for wound care itself. In managing a stage 4 pressure injury, the priority is proper wound cleaning and dressing materials rather than just securing them, so adhesive tape is secondary.

D. Cotton-tipped applicator: Cotton-tipped applicators are commonly avoided in wound care because they can leave fibers in the wound bed and potentially cause trauma or infection. They are not recommended for cleaning or applying medication to deep pressure ulcers, where more sterile, gentle methods are needed.