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

This is the correct answer. If a client requires endotracheal suctioning, it is likely due to respiratory distress or compromised airway clearance. Ensuring a patent airway and maintaining adequate oxygenation is the top priority, making endotracheal suctioning the first procedure to be performed.

B. Urinary catheter care:

Urinary catheter care is important for preventing infections and maintaining urinary function, but it is generally not as urgent as addressing respiratory distress. If the client is experiencing respiratory issues, addressing these concerns should take precedence.

C. Enteral feeding:

While enteral feeding is essential for providing nutrition, it is not typically as urgent as addressing respiratory needs. If a client requires endotracheal suctioning for respiratory support, it should be prioritized over enteral feeding.

D. Wound irrigation:

Wound irrigation is important for wound care, but it is generally not as time-sensitive as addressing respiratory needs. If the client's airway is compromised, it takes precedence over wound irrigation.

A. Prepare the client for surgery:
In emergency situations, if immediate intervention is required to save the client’s life or prevent significant harm, the principle of implied consent may apply. This means that if the client is unconscious and immediate treatment is necessary, healthcare providers may proceed with treatment under the assumption that the client would consent if able. However, this should be done in accordance with facility policies and legal guidelines.
B. Obtain consent from the surgeon:
The surgeon is not the appropriate person to obtain consent from in this situation. Informed consent should ideally come from the client or a legal surrogate decision-maker, depending on the circumstances. Surgeons are responsible for discussing the procedure with the patient or their authorized representative before surgery, but obtaining consent is not the nurse's role.
C. Contact the facility's ethics committee for guidance:
While the ethics committee may provide guidance in complex ethical situations, the immediate concern in this emergency situation is to address the client's life-threatening condition. The nurse should prioritize actions that ensure the client receives timely and necessary medical care.
D. Keep the client stable until a family member arrives to give consent:
While obtaining consent from a family member is ideal, waiting for consent can delay critical and time-sensitive interventions. In emergency situations, the priority is to provide necessary medical care promptly to stabilize the client. If there is no one available to give consent immediately, healthcare providers may proceed with necessary interventions to preserve life and limb.