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. Place the bedside table 0.9 m (3 feet) away from the bed:

While having a bedside table nearby can be convenient for clients to access essential items, the specific distance of 0.9 m (3 feet) is not a standard guideline for falls prevention. Placing the bedside table closer to the bed may actually improve accessibility for the client, but it's not the most crucial action for falls prevention in this scenario.

B. Provide the client with a night light.

Falls prevention strategies aim to create a safe environment for clients at risk of falling. Providing a night light helps improve visibility during nighttime, reducing the risk of falls due to poor lighting. It assists clients in navigating their surroundings safely, especially when getting out of bed during the night.

C. Elevate full-length side rails on both sides of the client's bed:

Using full-length side rails on the bed can increase the risk of entrapment and injury, especially for clients at risk of falls. Current evidence suggests that the use of physical restraints, such as full-length side rails, does not effectively prevent falls and may contribute to adverse outcomes.

D. Keep the client's room temperature at 18°C (64.4°F):

While maintaining a comfortable room temperature is important for client comfort, the specific temperature of 18°C (64.4°F) is not a standard guideline for falls prevention. Instead, ensuring a comfortable temperature range based on individual client preferences and environmental factors is appropriate.

A. Check the pH level of the client's gastric contents:

Checking the pH level of gastric contents is not typically necessary before administering intermittent tube feeding. pH testing of gastric contents is more commonly performed for clients with nasogastric tubes to confirm tube placement within the stomach. It is not routinely done before administering tube feeding through a percutaneous gastrostomy tube.

B. Check the patency of the client's tube every 8 hr:

While it is essential to check the patency of the tube regularly, every 8 hours may not be frequent enough, especially for clients receiving intermittent tube feedings. Tube patency should be checked before and after each feeding or medication administration to ensure proper function and prevent complications.

C. Place the client in a supine position:

Placing the client in a supine position is not specifically indicated for administering intermittent tube feedings. The client's position during tube feeding administration depends on individual factors such as comfort, mobility, and risk of aspiration. The nurse should position the client in a semi-upright or upright position (typically at a 30-45 degree angle) to reduce the risk of aspiration.

D. Flush the client's tube with 5 mL of water.

Flushing the client's tube with water helps ensure its patency and removes any residual feeding solution or gastric contents, reducing the risk of clogging and infection. Flushing with 5 mL of water is a common practice to maintain tube patency and should be done before and after each feeding and medication administration.