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. Repeat each exercise 10 times: Performing passive range of motion exercises 3 to 5 times per joint is usually enough to maintain joint flexibility and prevent stiffness. Repeating the exercises excessively may cause muscle fatigue or irritation, especially in immobile clients. The goal is to promote mobility without causing discomfort or harm.

B. Increase flexion during a muscle spasm: Forcing movement during a muscle spasm can increase pain and potentially cause injury to muscles or joints. The nurse should gently stop the exercise when a spasm occurs and allow the muscle to relax before continuing. Careful, slow movements help prevent exacerbation of muscle spasms.

C. Support each extremity above and below the joint: Supporting the extremity above and below the joint stabilizes the joint and surrounding tissues, reducing the risk of injury during passive movement. This technique also helps control the movement and minimizes discomfort for the client. Proper support is essential for safe and effective passive range of motion exercises.

D. Move the joint just past the point of resistance: Moving a joint beyond the point of resistance can cause tissue damage, pain, and joint injury. The nurse should stop movement at the point of resistance or the onset of discomfort, never forcing further motion. Respecting this limit preserves joint integrity and client safety.

A. Goggles: Goggles protect the eyes from splashes and should be removed after gloves and gown, once the risk of contamination is lower. Removing them too early can increase the risk of contamination if hands are still contaminated.

B. Gloves: Gloves are the most contaminated item after wound care and should be removed first to prevent spreading microorganisms to other personal protective equipment or the nurse’s skin. Proper glove removal technique reduces the risk of self-contamination.

C. Mask: Masks protect the respiratory tract and are typically removed last, after gloves, gown, and goggles, to maintain protection as long as possible. Removing the mask too early can expose the nurse to airborne particles.

D. Gown: The gown is removed after gloves because it is also contaminated but less so than gloves. Removing gloves first minimizes transferring contaminants from the gloves to the gown or other surfaces during removal.