The nurse cares for a client in 2-point soft wrist restraints to prevent them from pulling out their endotracheal tube. What action(s) should the nurse include in the client's care to prevent complications?

• Disinfecting a client's counter before administering oral medications: This practice reduces the number of microorganisms on surfaces to prevent infection, which is the principle of medical asepsis. It focuses on cleanliness and reducing contamination rather than creating a completely sterile environment.

• Covering the client and surrounding area with sterile drapes: Sterile drapes create a sterile field and prevent contamination of surgical or invasive sites. This is a key component of surgical asepsis, ensuring that instruments, supplies, and the environment remain free from microorganisms during procedures.

• Covering mouth and nose with a sleeve or elbow when coughing or sneezing: This prevents the spread of pathogens via droplets and maintains a clean environment. It is a basic principle of medical asepsis, which aims to reduce infection transmission through routine hygiene practices.

• Allowing only sterile-to-sterile contact: Maintaining a sterile field requires that sterile items only touch other sterile items. This is fundamental to surgical asepsis, preventing introduction of microorganisms during invasive procedures. Any break in sterile technique increases the risk of infection.

• Using sterile packaging for instruments and supplies: Sterile packaging preserves sterility until use, which is critical for surgical asepsis. It ensures that instruments and supplies remain free from microorganisms until the moment of use in invasive procedures.

• Using an autoclave to sterilize surgical instruments: Autoclaving uses high-pressure steam to destroy all microorganisms, achieving complete sterility. This process is a core component of surgical asepsis, making instruments safe for invasive procedures.

A. Face the direction of movement: Facing the direction of movement promotes proper body alignment and reduces twisting of the spine during repositioning. This technique improves balance and decreases the risk of musculoskeletal injury. Correct body mechanics are essential when making an occupied bed.

B. Stand with feet close together: Standing with feet close together narrows the base of support and reduces stability. Proper body mechanics require feet to be shoulder-width apart to maintain balance during movement. A stable stance helps prevent falls and back strain.

C. Reach across the bed to grab clean linens: Reaching across the bed causes spinal twisting and overextension of the arms. This movement increases the risk of back injury and shoulder strain. Linens should be positioned within close reach to support ergonomic practice.

D. Maintain the bed in low and locked position: The bed should be locked for safety, but it should be raised to a comfortable working height during care. Keeping the bed low increases the need for bending and strain. Bed height adjustment is part of safe body mechanics.