Share This Link

Orient the client to the room: Orientation is important for patient comfort and safety, especially after anesthesia when confusion may be present. However, it is not the priority action immediately upon arrival, as physiological stability must be assessed first before addressing environmental familiarity.

Assure the call light is within reach: Ensuring the call light is accessible supports patient safety and autonomy, particularly in preventing falls or unmet needs. Despite its importance, this intervention follows confirmation of the patient’s immediate physiological status.

Call the provider for orders: Orders are typically already established prior to transfer from the PACU. Contacting the provider without first assessing the patient may delay identification of urgent postoperative complications such as airway compromise, hemorrhage, or hemodynamic instability.

Metabolic acidosis: Metabolic acidosis is characterized by a decreased pH (<7.35) and a decreased bicarbonate (HCO₃⁻ <22 mEq/L) as the primary disturbance. In this scenario, although the pH is low (7.19), the bicarbonate level is within normal range (26.2 mEq/L), indicating that the acidosis is not metabolic in origin but rather due to another primary process.

Metabolic alkalosis: Metabolic alkalosis presents with an elevated pH (>7.45) and increased bicarbonate levels. The patient’s pH is significantly decreased, ruling out alkalosis. Additionally, the bicarbonate level is not elevated enough to suggest a primary metabolic alkalotic process.

Normal ABG results: Normal ABG values include a pH of 7.35–7.45, PaCO₂ of 35–45 mmHg, and HCO₃⁻ of 22–26 mEq/L. This patient’s pH is markedly acidotic and the PaCO₂ is significantly elevated at 65.8 mmHg, indicating an abnormal acid-base imbalance.

Hyperphosphatemia: Elevated phosphate levels are commonly associated with renal failure and can lead to hypocalcemia due to calcium-phosphate binding. Clinical manifestations often include muscle cramps, tetany, and sometimes soft tissue calcifications. Intense thirst, dry mucous membranes, and dehydration are not characteristic of hyperphosphatemia.

Hyperkalemia: Hyperkalemia primarily affects cardiac and neuromuscular function, presenting with symptoms such as muscle weakness, paresthesia, and potentially life-threatening dysrhythmias. Gastrointestinal symptoms may include diarrhea rather than nausea and vomiting, and it does not typically cause pronounced thirst or dry mucosa.

Hypocalcemia: Hypocalcemia is associated with neuromuscular excitability, including tetany, muscle spasms, seizures, and positive Chvostek’s or Trousseau’s signs. It does not present with dehydration-related symptoms such as extreme thirst or dry oral mucosa.

Client who urinates frequently due to diuretic therapy: Increased urination may lead to fluid loss and potential dehydration if not managed, which can affect skin turgor and perfusion. However, with adequate fluid replacement, this factor alone does not significantly impair the physiological processes required for wound healing.

Client with limited mobility recovering from knee surgery: Limited mobility can increase the risk of pressure injuries due to prolonged pressure over bony prominences and reduced circulation. While this may contribute to delayed healing if a wound develops, it does not inherently impair systemic healing processes as chronic metabolic and vascular conditions.

Client who is NPO one day before abdominal surgery: Short-term NPO status typically does not result in significant nutritional deficiency or impair wound healing. The body’s nutrient stores and perioperative management generally compensate for this brief period without oral intake, making it a minimal risk factor.

Having another nurse assist to perform the bed bath: Assistance may be necessary for safety and efficiency, especially with immobile clients, but it does not inherently convey emotional presence or therapeutic communication. The focus is on task completion rather than directly expressing caring behaviors to the client.

Making sure that daily hygiene was completed on time: Timeliness reflects organization and adherence to routine care, but it does not address the interpersonal aspect of nursing. Completing hygiene on schedule ensures physical care needs are met but does not demonstrate compassion or emotional connection.

Maintaining eye contact with the client throughout: Eye contact is a valuable communication tool for conscious patients, but in a comatose client, it does not provide meaningful interaction. Since the client cannot visually engage, this action does not effectively convey caring compared to auditory and tactile approaches.

Vitamin E.: Vitamin E has antioxidant properties and may support skin integrity, but it is not a primary nutrient required in large amounts for wound healing. Excessive supplementation can even interfere with vitamin K–dependent clotting, and it does not significantly contribute to collagen synthesis or tissue repair compared to protein.

Fats.: Fats provide a concentrated energy source and are important for cell membrane integrity and absorption of fat-soluble vitamins. However, they do not directly support the structural rebuilding of tissue to the same extent as protein, making them a secondary consideration in wound healing.

Carbohydrates.: Carbohydrates supply energy required for cellular metabolism and protein sparing, but they do not directly contribute to tissue repair or immune function. While adequate caloric intake is necessary, increasing carbohydrates alone does not address the increased protein demands associated with pressure ulcer healing.

Active listening: Active listening is a therapeutic communication skill that involves attentiveness, validation, and appropriate responses to the patient’s concerns. Elderspeak, which includes patronizing language, exaggerated intonation, and simplified speech, does not promote engagement or mutual respect, and therefore does not enhance active listening behaviors.

Short-term memory loss: Short-term memory loss is a cognitive impairment commonly associated with aging or neurological conditions such as dementia. Elderspeak does not directly cause memory deficits; rather, it can negatively impact emotional well-being and communication effectiveness without altering cognitive function.

Compliance: Compliance implies cooperation with care and adherence to treatment plans. Elderspeak often undermines patient dignity and autonomy, which can reduce trust and willingness to cooperate, making increased compliance an unlikely outcome.

Deep tissue injury: Deep tissue injuries typically present as a localized area of intact or non-intact skin with persistent deep red, maroon, or purple discoloration due to underlying soft tissue damage. They are not usually described as shallow, oozing ulcers with irregular borders, which differentiates them from the findings here.

Stage 2 pressure ulcer: Stage 2 pressure injuries involve partial-thickness skin loss with exposed dermis and appear as shallow, open ulcers or blisters. They are usually associated with pressure over bony prominences and do not typically present with irregular borders and chronic oozing on the lower leg, nor with surrounding discoloration related to venous insufficiency.

Arterial ulcer: Arterial ulcers are typically located on distal areas such as the toes or lateral ankle and present with well-defined, “punched-out” edges. The wound bed is often pale or necrotic with minimal drainage due to poor blood supply, which contrasts with the oozing, irregular ulcer described.