A home health nurse is caring for a client who has terminal cancer. The client tells the nurse they wish to stop their chemotherapy treatments. Which of the following statements should the nurse make?

Rationale:
A. A client who has dementia and is incontinent of urine: Cognitive impairment and incontinence significantly increase the risk for pressure injuries. Dementia may limit mobility and the ability to communicate discomfort, while moisture from incontinence leads to skin breakdown, making this client the highest risk.

B. A client who has had a recent myocardial infarction: While immobility after a myocardial infarction can contribute to pressure injury risk, this client typically has fewer direct risk factors compared with incontinence and cognitive impairment.

C. A client who has a T-tube following an open cholecystectomy: Postoperative clients with a T-tube are at moderate risk due to temporary immobility, but they usually maintain mobility and can reposition, reducing overall risk compared with incontinent or cognitively impaired clients.

D. A client who is 2 days postoperative following orthopedic surgery: Early postoperative orthopedic clients are at risk due to immobility, but with appropriate repositioning, pressure-relieving devices, and monitoring, their risk is generally lower than a client with incontinence and dementia.

Rationale:
A. A client who has an open compound fracture of the humerus: A compound fracture involves broken bone protruding through the skin and carries a risk of infection and significant blood loss. This client requires urgent care and should be tagged yellow (delayed) or red (immediate) depending on other injuries.

B. A client who has multiple facial lacerations: Facial lacerations that are not life-threatening can be treated after higher-acuity clients are stabilized. These clients are mobile, alert, and their injuries are minor, which qualifies them for a green tag (minimal, “walking wounded”).

C. A client who has a puncture wound in the right lower lung: A puncture wound to the lung can compromise respiratory function and oxygenation. This is a life-threatening injury, requiring immediate intervention and a red tag.

D. A client who has full-thickness burns over the lower extremities: Full-thickness burns compromise skin integrity and can lead to fluid loss, infection, and shock. This client needs urgent treatment and should be tagged red (immediate) or yellow (delayed) depending on the extent of burns and airway status.