A nurse is assisting in the care of a client who is scheduled for an appendectomy.

Exhibits

The nurse is assisting with preparing the client for surgery. Select the 3 findings that require follow-up prior to surgery.

A. Locks the wheelchair after transferring the client: Locking the wheelchair should occur before the transfer to prevent it from rolling during the movement. Locking it after transferring compromises client safety and increases the risk of falls or injury.

B. Places the bed in a high position before transferring the client to the wheelchair: The bed should be placed in the lowest safe position to allow the client’s feet to touch the floor and to ease the transition to a lower surface like a wheelchair. A high bed position creates an unsafe height differential.

C. Uses a narrow stance when assisting the client to the wheelchair: A wide stance provides a stronger, more stable base of support, which is essential for safe body mechanics during a transfer. A narrow stance can lead to imbalance and injury to the AP or client.

D. Positions the wheelchair parallel to the client's bed: Positioning the wheelchair parallel or at a slight angle to the bed allows for easier and safer transfers. This minimizes turning and supports a smoother pivot, reducing strain on both the client and caregiver.

A. "I will keep the drainage bag below the level of my waist.": Keeping the drainage bag below the waist or bladder level is essential to prevent backflow of urine, which can lead to infection or bladder distention. This practice promotes proper drainage by gravity and helps reduce the risk of urinary tract infections.

B. "I will apply antiseptic ointment to the tip of my penis.": Applying antiseptic ointment is generally not recommended unless specifically prescribed by a healthcare provider. Routine use of ointments can irritate the urethral area or disrupt normal flora, potentially increasing infection risk.

C. "I will empty my drainage bag once a day.": Emptying the drainage bag only once daily is insufficient and increases the risk of urinary stasis and infection. The bag should be emptied regularly, at least every 8 hours or when it is two-thirds full, to maintain proper flow and reduce bacterial growth.

D. "I will clamp the tube when I go for a walk.": Clamping the catheter tubing can cause urine retention and increase the risk of bladder overdistention and infection. The tubing should remain open to allow continuous drainage regardless of activity level to ensure bladder emptying and prevent complications.