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Complete every dressing change using sterile technique: Not all wounds require sterile technique; many chronic or noninvasive wounds are appropriately managed with clean technique. Using sterile technique unnecessarily increases cost and does not improve outcomes for all wound types. Best practice involves selecting technique based on wound type and setting.

Quickly remove any tape from the client's skin before beginning: Rapid tape removal increases the risk of skin tears, especially in older adults or those with fragile skin. Proper technique involves supporting the skin and removing tape slowly in the direction of hair growth.

Document wound care at the end of the shift to save time: Delayed documentation increases the risk of omitted or inaccurate information regarding wound appearance and interventions. Wound care findings should be documented promptly after completion to ensure accuracy and continuity of care. Timely documentation supports clinical decision-making.

Disregard client facial grimacing during the procedure and continue quickly: Facial grimacing is a nonverbal indicator of pain and should prompt reassessment rather than be ignored. Continuing without addressing discomfort can increase pain perception and anxiety. Client-centered care requires ongoing pain evaluation during wound care.

Cleanse the wound with cold solution to help numb the area: Cold solutions can increase discomfort and cause vasoconstriction, which may impair local circulation and healing. Wound cleansing solutions are typically warmed to body temperature to enhance comfort. Cold application is not recommended for routine wound care.

Remove the dressing quickly and without warning to reduce anxiety: Sudden removal can increase pain and distress, particularly if the dressing adheres to the wound bed. Explaining the procedure and removing dressings slowly with appropriate moisture reduces tissue trauma. Clear communication supports comfort and trust during care.

Open the sterile drape and place it on the table: Opening sterile supplies before preparing the environment increases the risk of contamination. The surface must be clean, dry, and positioned appropriately before any sterile items are opened. Environmental preparation precedes establishing the sterile field.

Put on sterile personal protective equipment: Sterile gloves and PPE are donned after the sterile field is set up, not before. Donning them too early increases the risk of contamination during setup. Hand hygiene and environment preparation come first.

Arrange sterile instruments on the sterile field: Sterile instruments are handled only after the sterile field has been properly established. Placing instruments occurs later in the setup sequence. This action depends on prior preparation of the field.

An adolescent client with diabetes mellitus who is admitted for hyperglycemia: Diabetes can impair circulation and wound healing, but adolescents are generally mobile and able to reposition independently. Short-term hyperglycemia alone does not create sustained pressure over bony prominences. Mobility significantly reduces pressure injury risk.

An older adult client who is recovering from a sinus infection: Advanced age can increase vulnerability to skin breakdown, but a sinus infection does not typically limit mobility or sensation. Clients who are alert and ambulatory can relieve pressure independently. Risk remains relatively low without immobility.

An adult client with a spinal cord injury who engages in daily physical therapy: Although spinal cord injury increases baseline risk due to sensory deficits, regular physical therapy promotes mobility, circulation, and pressure relief. Active repositioning and therapeutic movement reduce prolonged pressure exposure. Consistent mobility lowers overall risk.

Stand with feet close together: Standing with feet close together narrows the base of support and reduces stability. Proper body mechanics require feet to be shoulder-width apart to maintain balance during movement. A stable stance helps prevent falls and back strain.

Reach across the bed to grab clean linens: Reaching across the bed causes spinal twisting and overextension of the arms. This movement increases the risk of back injury and shoulder strain. Linens should be positioned within close reach to support ergonomic practice.

Maintain the bed in low and locked position: The bed should be locked for safety, but it should be raised to a comfortable working height during care. Keeping the bed low increases the need for bending and strain. Bed height adjustment is part of safe body mechanics.

Perform exercises until you feel pain in the joint: Active ROM exercises should not cause pain, as pain can indicate joint injury, inflammation, or overextension. Exercising into pain may worsen tissue damage and reduce adherence. Discomfort signals the need to stop or modify movement.

Expose the entire body to observe overall movement: Only the joint being exercised needs to be exposed to preserve client comfort and dignity. Full-body exposure is unnecessary for ROM instruction. Observation can be effectively performed one joint at a time.

Perform exercises rapidly to increase muscle strength: Rapid movements increase the risk of joint strain and muscle injury, especially in clients with limited mobility. Active ROM focuses on maintaining flexibility and joint motion rather than building strength. Movements should be slow, controlled, and deliberate.