The nurse provided discharge teaching to the client's family on preventing pressure injuries at home. Which statement made by the family member indicates a need for further instruction?

A. A client with dementia who refuses to have the pulse oximeter on their finger: While monitoring oxygen saturation is important, the client is currently stable and not showing signs of acute distress. This situation can be addressed after more urgent needs are met. Refusal does not immediately threaten life or safety.

B. A client with a blood pressure of 138/86 mmHg who is experiencing acute pain: Mildly elevated blood pressure is expected with pain and is not immediately life-threatening. Pain management is important but does not take priority over a potential infection or acute physiologic instability.

C. A client with delirium who is confused and has a temperature of 101.8 F (38.8 C): Fever in a delirious client may indicate infection or sepsis, which can rapidly deteriorate. Delirium combined with hyperthermia signals acute physiologic compromise requiring immediate assessment and intervention. This client has the highest priority.

D. A client with a heart rate of 112 who is experiencing elevated levels of anxiety: Mild tachycardia associated with anxiety is usually self-limiting and not immediately life-threatening. Anxiety can be managed after addressing clients with potential systemic compromise.

A. Sterile items can be used if they touch clean surfaces: Contact with clean but nonsterile surfaces contaminates sterile items. Sterility requires that items only touch other sterile surfaces or instruments. Using contaminated items violates aseptic principles.

B. Sterile objects can be handled with clean gloves: Clean gloves are not sterile and can transfer microorganisms to sterile items. Only sterile gloves or sterile instruments should touch sterile objects to maintain asepsis.

C. Sterile objects must remain within the sterile field: Sterile items must stay within the designated sterile field to prevent contamination. Movement outside the field exposes items to microorganisms from the environment or nonsterile surfaces.

D. Sterile fields must always be kept in sight to be sterile: Maintaining visual control ensures the field is not accidentally contaminated. Out-of-sight fields may be inadvertently compromised by environmental exposure or improper handling.

E. Sterile items must be kept above waist level: Sterile items below waist level are considered contaminated because of potential contact with clothing, floors, or nonsterile surfaces. Keeping items above waist level supports aseptic technique.