The nurse is assessing the way a client ambulates. Which aspects are the nurse assessing during ambulation? Select all that apply. One, some, or all may be correct

A. Put the patient on NPO status: Prevents oral intake before surgical evaluation and possible return to the operating room; also reduces risk of aspiration if anesthesia is needed.

B. Apply a cold compress to the exposed bowel: Avoids this -cold compresses can cause vasoconstriction and tissue damage; they are not recommended for exposed viscera.

C. Notify the surgical team immediately: Timely surgical notification is essential because evisceration is an emergency that usually requires operative management.

D. Place dressing dampened with sterile water/saline over the area: A sterile, saline-moistened dressing protects exposed bowel from drying and contamination while awaiting surgical intervention.

E. Elevate the head of the bed 90 degrees: Avoid positioning that increases intra-abdominal pressure; the recommended position is usually low Fowler’s with knees slightly flexed to reduce tension on the wound.

A. It doesn't matter where the IM injection is given: Site selection matters -factors such as medication type, injection volume, patient age, and muscle mass determine the appropriate IM site (e.g., deltoid, ventrogluteal, vastus lateralis).

B. IM injections should be given using the Z-Track method: The Z-track technique is recommended for certain IM medications to displace subcutaneous tissue and prevent medication from tracking back into subcutaneous tissue, reducing irritation and leakage.

C. The site will not be sore at all after this type of injection: Some soreness or local tenderness is common after IM injections due to muscle penetration and the medication; absence of soreness is not typical for all IM injections.

D. IM injections are given at a 15-degree angle: IM injections are administered at a 90-degree angle to ensure the needle reaches muscle tissue; more shallow angles are used for subcutaneous injections.