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. Reposition the client every 4 hours:

While repositioning is essential for preventing pressure injuries, the recommended frequency for repositioning depends on the individual client's condition, risk factors, and facility protocols. Four-hour intervals may not be sufficient for some clients, especially those at higher risk, and more frequent repositioning may be necessary.

B. Raise the head of the client's bed to a 60° angle:

Raising the head of the bed to a 60° angle may help with positioning for comfort and respiratory support but does not directly address the prevention of pressure injuries. In fact, maintaining the head of the bed elevated at such a high angle for prolonged periods could potentially increase pressure on the sacrum and increase the risk of pressure injuries in other areas.

C. Ensure the client's heels are not touching the mattress.

Keeping the client's heels off the mattress helps to alleviate pressure on this vulnerable area, reducing the risk of pressure injuries. Pressure injuries commonly occur over bony prominences when pressure is exerted on the skin over an extended period, leading to tissue damage. The heels are particularly susceptible due to the limited tissue padding and continuous pressure when lying in bed. Elevating the heels with appropriate support, such as foam pads or pillows, helps to redistribute pressure and minimize the risk of pressure injuries.

D. Massage the client's bony prominences:

Massaging bony prominences is contraindicated for clients at risk of pressure injuries as it can increase friction and shear forces on the skin, leading to tissue damage. Massage should be avoided over areas prone to pressure injuries to prevent further trauma to the skin.

A. Corneas with an opaque appearance:

An opaque appearance of the corneas indicates an abnormal finding and could suggest a pathological condition such as corneal edema, scarring, or infection. The corneas should normally be clear and transparent to allow light to pass through to the retina.

B. Pupils that are 8 to 9 mm in diameter:

Pupils that are 8 to 9 mm in diameter are abnormally large and dilated. Normal pupil size varies between approximately 2 to 4 mm in diameter under normal lighting conditions. An 8 to 9 mm diameter suggests mydriasis, which may be caused by various factors such as medications, neurological conditions, or trauma.

C. Eyelashes that curl slightly outward.

Eyelashes that curl slightly outward are a normal finding and help to protect the eyes by preventing foreign particles from entering. This finding is considered within the range of normal anatomy and physiology of the eye.

D. Eyelids that blink involuntarily 30 to 35 times per minute:

While blinking is a normal physiological response that helps to keep the surface of the eye moist and clear debris, the rate of involuntary blinking typically ranges from 15 to 20 times per minute in adults, not 30 to 35 times per minute. A higher rate of blinking could indicate irritation, dryness, or other ocular discomfort.