A nurse is caring for a client who is scheduled for surgery.

Exhibit 1

Medical History

0800:

Client has a history of malnutrition, hyperlipidemia, and diabetes mellitus.

Mini Nutritional Assessment screening tool score of 7 points (0 to 14 points)

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. Read the medication label twice prior to administration.

This action is crucial to ensure that the nurse correctly identifies the medication and verifies the dosage before administering it to the patient. By double-checking the medication label, the nurse can confirm that they have the right medication, in the correct dose, for the correct patient, and via the correct route. This practice helps prevent medication errors and promotes patient safety.

B. Use one patient identifier prior to medication administration.

Explanation: Using at least one patient identifier, such as the patient's name or date of birth, is a standard safety practice to confirm the patient's identity before administering any medication. This helps ensure that the medication is given to the right patient, reducing the risk of administering medications to the wrong individual.

C. Access the online drug formulary for an unfamiliar medication.

Explanation: While it's essential to be knowledgeable about medications, relying solely on an online drug formulary for unfamiliar medications may not be sufficient for safe administration. Online resources can provide valuable information, but they should supplement, not replace, comprehensive education and understanding of medications. Nurses should have a solid understanding of the medications they administer and consult additional resources as needed.

D. Ask the client if they have ever taken a similar medication.

Explanation: While it's important to gather information from the patient about their medical history and previous experiences with medications, solely relying on the patient's response may not be sufficient for ensuring safe medication administration. Patients may not always accurately recall or provide complete information about their medication history. Nurses should verify medication orders through appropriate channels and rely on documented medical records whenever possible to confirm medication history and suitability for administration.

A.Placing gauze under the flanges of the tracheostomy tube is not recommended because it can create a breeding ground for bacteria and increase the risk of infection.Pre-cut gauze pads should be used to avoid loose fibers from entering the stoma.

B.Full-strength hydrogen peroxide is too harsh and can cause skin irritation or damage. When performing tracheostomy care, the skin around the stoma should be cleaned with a mild saline solution.

C.A collar with hook-and-loop fastenersis commonly used to secure the tracheostomy tube in place. This collar should be snug enough to hold the tube securely but not too tight to cause discomfort or restrict airflow. The collar helps prevent accidental dislodgement of the tracheostomy tube, ensuring it remains properly positioned.

D.Sterile gloves should be worn when cleaning the inner cannula of the tracheostomy tube to minimize the risk of introducing pathogens.