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. Giving the client's medications between meals:

Administering medications between meals does not address the risk of aspiration associated with dysphagia. Moreover, timing of medication administration in relation to meals may vary depending on the specific medication requirements.

B. Assisting the client into semi-Fowler's position:

While positioning can play a role in facilitating swallowing, semi-Fowler's position alone may not be sufficient to address the risk of aspiration in clients with dysphagia. Moreover, simply positioning the client without considering other factors may not ensure safe medication administration.

C. Encouraging the client to use a straw to take the medication:

Using a straw might not be appropriate for clients with dysphagia as it can increase the risk of aspiration, especially if the client has difficulty controlling the flow of liquid or coordinating swallowing movements.

D. Administer the client's medications one at a time.

Dysphagia refers to difficulty in swallowing, which can increase the risk of choking or aspiration. Administering medications one at a time ensures that each pill is swallowed safely and reduces the risk of aspiration. It allows the nurse to closely monitor the client's ability to swallow each medication and intervene if necessary.

A.An 18-gauge, 1-inch needle is too large for subcutaneous injections like heparin. Heparin is administered subcutaneously using a smaller needle (e.g., 25- or 27-gauge) to minimize tissue trauma.

B.Heparin should be injected into the subcutaneous tissue, typically in the abdomen, but at least 2 inches (5.1 cm) away from the umbilicus to avoid the rich vascular supply and reduce the risk of bleeding or bruising in this area.

C.Air bubbles should not be expelled from prefilled syringes of heparin because the air bubble ensures the full dose is delivered and helps prevent medication from leaking into the subcutaneous tissue, reducing bruising at the injection site. Prefilled syringes are designed with this in mind.

D.Massaging the injection site after administering heparin increases the risk of bruising and bleeding due to the anticoagulant effects of heparin. Gentle pressure may be applied to prevent bleeding, but massaging should be avoided.