A nurse is assisting in the care of a client who is receiving newly prescribed IV antibiotics. Which of the following findings should the nurse report immediately?

Rationale:

A. While the client's feelings about never marrying are important, they do not represent an immediate health risk or safety concern.

B. Poorly fitting dentures can affect the client's quality of life and ability to eat, but they do not represent an immediate health risk or safety concern.

C. While having no living family can be a social concern, it does not represent an immediate health risk or safety concern.

D. The client being sedentary throughout most of the day is a risk factor for numerous health problems, including cardiovascular disease, obesity, and decreased mobility. It is also a modifiable risk factor that can be addressed to improve the client's health and quality of life. Encouraging the client to engage in regular physical activity is a priority.

A. Cleanse the wound with cotton balls – Cotton fibers can shed and leave debris in the wound, increasing the risk of infection. Gauze or irrigation is preferred.
B. Use a 10-mL syringe filled with cleansing solution – A 10-mL syringe does not provide sufficient pressure for effective irrigation. A 30- to 60-mL syringe is typically recommended.
C. Hold the syringe tip 2.5 cm (1 in) above the upper end of the wound – This ensures appropriate pressure and prevents contamination while effectively flushing out debris.
D. Dry the wound bed with gauze squares – The wound bed should be kept moist to promote healing; only the surrounding skin should be dried if necessary.