A nurse is preparing to perform passive range of motion exercises for a client who is immobile. Which of the following actions should the nurse plan to take?

A. The WBC count was not provided in the nurse’s notes or diagnostic section. Without any indication of infection or abnormal lab values, there is no basis to report WBC.

B. Although the pain level is mild (2/10), it may be contributing to anxiety, increased heart rate (110/min), and elevated BP (158/96 mm Hg). Report in context as part of a comprehensive assessment. Also, confirming that the pain is not worsening or atypical in nature is essential preoperatively.

C. The abdomen is soft, rounded, non-distended, with no tenderness, and active bowel sounds in all four quadrants — all normal postoperative readiness findings for abdominal surgery.

D. Knowing the blood type is routine pre-op procedure and is not an abnormal or urgent finding that needs immediate reporting. It is only relevant if transfusion is anticipated, which is not suggested here.

E. The client is requesting further details about the risks and benefits of surgery, which raises a legal and ethical concern about informed consent. The provider must ensure the client fully understands the procedure, otherwise surgery cannot proceed.

F. This is significantly elevated compared to baseline (126/74). Pre-op hypertension can increase surgical and anesthesia risk and should be evaluated further. It may be due to anxiety, pain, or another condition.

G. Platelet count values were not given in the scenario. Without abnormal lab results or bleeding concerns, there is no indication to report this.

H. This is lower than the previous baseline (97%). An SpO₂ < 94% on room air can signal underlying respiratory issues, atelectasis, sedation effects, or cardiac dysfunction, all of which should be addressed preoperatively.

I. The client ate breakfast at 0730 before a scheduled procedure, violating NPO (nothing by mouth) protocol. This significantly increases the risk of aspiration under anesthesia and must be reported immediately. The surgery may need to be rescheduled.

J. Capillary refill < 2 seconds is normal, indicating adequate peripheral perfusion. No issues with circulation are noted, so there's no reason to notify the provider.

A. Instruct the client to blink his eyes as a response: Expressive aphasia affects a person's ability to speak or write, but comprehension is often intact. Encouraging nonverbal communication methods such as blinking for "yes" or "no" responses can help the client effectively express needs and participate in care decisions without requiring speech.

B. Increase voice volume when speaking to the client: Raising the volume does not assist clients with expressive aphasia, as their difficulty lies in expression rather than hearing. Speaking louder can be perceived as frustrating or disrespectful and may not improve understanding or communication for the client.

C. Avoid using hand gestures: Hand gestures and facial expressions can enhance communication for individuals with aphasia by providing visual cues. Avoiding gestures removes a valuable tool that may help the client interpret and respond to messages, especially when they cannot verbalize thoughts.

D. Enunciate words slowly: While speaking clearly is beneficial in many communication disorders, expressive aphasia primarily impairs output, not comprehension. Enunciating slowly may not help the client respond more effectively and is more useful in receptive or global aphasia cases.