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. An assistive personnel raises all four side rails of a client's bed before leaving the room: Raising all four side rails can be considered a form of restraint and poses a safety risk, especially if the client attempts to climb over them. It can increase the risk of falls and injury, particularly in confused or restless clients.

B. An assistive personnel places a weight-sensitive sensor mat on the mattress beneath a client's buttocks: This is not a safety hazard; it's a fall prevention measure. These sensor mats are designed to alert staff when a client attempts to get up, helping prevent falls in at-risk individuals.

C. A client who has bilateral wrist restraints has a capillary refill of less than 2 seconds:
A capillary refill of less than 2 seconds is within normal limits and indicates that circulation to the hands is intact. This suggests that the restraints are not too tight and do not currently pose a circulatory risk to the client.

D. A client who has a transcutaneous electrical nerve stimulation unit reports a buzzing sensation at the application site: A mild buzzing or tingling sensation is an expected and normal effect of a TENS unit. It does not indicate a malfunction or a safety issue unless it becomes painful or the skin shows signs of irritation or burns.

A. Have the client perform heel-to-toe walking: Heel-to-toe walking (tandem gait) assesses balance and coordination by challenging the client’s ability to maintain stability during a narrow base of support. Difficulty with this test can indicate problems with cerebellar function or proprioception, which are essential for balance.

B. Perform Weber’s test: Weber’s test evaluates hearing by assessing bone conduction and is not related to balance assessment. It helps differentiate between conductive and sensorineural hearing loss but does not provide information about vestibular function.

C. Check for a positive Babinski reflex: Babinski reflex testing assesses neurological function of the corticospinal tract but does not evaluate balance. A positive Babinski indicates upper motor neuron damage but is unrelated to equilibrium or postural control.

D. Perform the Romberg test: The Romberg test evaluates proprioception and balance by assessing the client’s ability to maintain standing posture with eyes closed. A positive Romberg sign suggests impaired proprioception or vestibular dysfunction affecting balance.

E. Have the client lie in bed and use his heel to draw a line on the opposite shin: This test evaluates coordination and proprioception, important components of balance, by assessing precise lower limb control. Difficulty performing this task may indicate issues with neuromuscular control or proprioception.