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. "The lower end of the sling goes below the client's calves." The lower end of the sling should support the thighs and buttocks but typically does not extend below the calves. Positioning the sling incorrectly can cause discomfort or injury during the lift.

B. "The sides of the sling are for the client to hold on to." While some slings have loops for the caregiver to grasp, clients usually do not hold onto the sling sides during the lift, as this could interfere with safe handling and stability.

C. "This type of device is useful for a client who cannot assist." Mechanical lifts are specifically designed to safely transfer clients who have little or no ability to assist with moving. This reduces injury risk for both client and caregiver and ensures safe mobility.

D. "The device requires the client to use upper body strength." Mechanical lifts minimize the need for client effort, especially upper body strength. They are intended for clients unable to bear weight or assist, so reliance on client strength contradicts the device’s purpose.

A. Explain that the treatment is both safe and therapeutic: Providing reassurance about the safety and effectiveness of the procedure may be informative, but it can unintentionally pressure the client to consent. It does not respect the client’s autonomy or support their right to make independent healthcare decisions.

B. Tell the client that the procedure is necessary: Telling the client a procedure is necessary can sound coercive and may disregard their legal and ethical right to refuse treatment. Nurses must prioritize respecting the client's decisions, even if those decisions involve refusing recommended medical care.

C. Notify the client's loved ones of the client's refusal of the procedure: Informing family members without the client’s consent may breach confidentiality and is not appropriate unless the client is unable to make informed decisions. Client autonomy must be preserved, and their refusal should be respected unless there is an immediate risk of harm.

D. Inform the client they have the right to refuse treatment: Clients have the legal and ethical right to refuse any medical intervention, even if it is life-sustaining. The nurse’s role includes advocating for the client’s autonomy, ensuring informed consent, and supporting their decision without judgment or pressure.