A nurse is reviewing the medical record for a client who has a health care-associated infection (HAI). The nurse should identify which of the following findings as a risk factor for acquiring an HAI?

A) Each movement is repeated 5 times by the patient: While active range-of-motion (ROM) exercises often involve repetition, the key goal of passive ROM exercises (when the nurse is assisting the patient) is not to have the patient repeat movements. Instead, the nurse should ensure the patient’s joints are moved gently to their fullest range without causing discomfort or damage. Repeating movements a specific number of times isn't a required approach for passive ROM.

B) Each movement is moved just to the point of resistance by the nurse: This technique is the most appropriate when performing passive ROM exercises. The nurse should gently move the joint through its range of motion and stop at the point where resistance is felt, but without pushing into pain or forcing movement beyond the joint’s natural limits. This approach helps prevent injury while still providing the necessary mobility and flexibility.

C) Each movement is completed quickly and smoothly by the nurse: While the movement should be smooth, it should never be rushed or performed quickly, as that can cause strain or discomfort. ROM exercises should be done slowly and deliberately to avoid injury and to allow the joints to move through their full range of motion without abrupt movements. Quick motions could increase the risk of joint or muscle injury.

D) Each movement is performed until the patient reports pain: ROM exercises should be performed gently and within the range that does not cause pain. The goal is to maintain joint flexibility and prevent contractures, not to push the patient into pain. If the patient reports pain, the nurse should stop immediately to avoid injury and reassess the approach to ROM exercises. Pain should never be a target for achieving range of motion.

A) The client should first move the strong leg, then the weak one:
This instruction is not appropriate for cane use. When using a cane, the client should move the cane forward first, followed by the weak leg, and then the strong leg. This ensures proper support and balance while ambulating. Moving the strong leg first could cause instability and increase the risk of falls.

B) When the client moves, he should move the cane forward first:
This statement is partly correct, but it's only one part of the proper technique for cane use. The cane should be moved forward first, but then the weak leg should follow, and the strong leg should move last. This sequence helps the client maintain balance while using the cane.

C) The client should hold the cane on the weak side of his body:
This is the correct instruction. The cane should be held on the weak side (the side with the injury or decreased strength) to provide support and maintain balance while ambulating. Holding the cane on the weak side helps to transfer weight from the weak leg to the cane, improving stability and mobility.

D) The grip should be level with the client's wrist:
This statement is partially correct but lacks clarity. The cane's grip should be level with the client's wrist when standing upright, which ensures that the client can hold the cane with a slightly bent elbow, promoting better posture and more effective use of the device. However, it is essential to make sure the cane height is adjusted to the individual's specific needs, as the wrist level may not always be ideal for every client.