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

Exhibits

The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing. Select all that apply.

A. Administer an antibiotic: There is no indication of infection; WBC count is normal, and the client is afebrile. The reported symptoms relate to lifestyle and substance use rather than a bacterial illness, making antibiotics unnecessary.

B. Limit alcohol intake to 2 drinks per day: The client uses 4–5 beers nightly to sleep, indicating alcohol misuse that can exacerbate hypertension and negatively impact sleep quality. Limiting intake supports cardiovascular and liver health, and aligns with public health recommendations.

C. Limit foods high in potassium: The client’s potassium level is within the normal range (3.7 mEq/L), and there is no evidence of kidney dysfunction or hyperkalemia. Restricting potassium is unwarranted and could risk deficiency.

D. Administer a diuretic: The client has elevated blood pressure (162/90 mm Hg), which may require pharmacologic intervention. Diuretics are a common first-line treatment for hypertension as they reduce fluid overload and vascular resistance.

E. Keep daily fat intake to less than 35%: The client’s LDL (210 mg/dL) and total cholesterol (248 mg/dL) levels are significantly elevated. Reducing total fat intake, particularly saturated fats, is essential for lowering cholesterol and reducing cardiovascular risk.

F. Place on 2,300 mg sodium diet: A sodium-restricted diet is standard for managing hypertension. The American Heart Association recommends limiting sodium to help control blood pressure and reduce cardiovascular complications.

A. "Why do you think they're not eating?”: This question may come across as confrontational or accusatory, which can make the child feel defensive. It does not foster open communication or help the nurse gather specific, objective information.

B. "They may need a feeding tube.": Introducing a feeding tube early in the discussion can cause unnecessary alarm. It is a significant intervention that should only be considered after a thorough assessment and evaluation by the provider.

C. "Tell me more about what happens at mealtime.": This open-ended, nonjudgmental question encourages the child to provide detailed information about the client's eating habits, environment, and possible stressors, helping the nurse assess the situation more effectively.

D. "I'm sure it's nothing serious and their appetite will return soon.": This response is dismissive and minimizes the child’s concern. It may hinder further communication and delay identifying potential underlying issues with the client's nutrition.