A nurse is assisting in the care of a client during surgery. Which of the following should the nurse identify as supporting a safe, therapeutic environment?

The grounding pad is positioned near the client's surgical site.

The client's surgical site is shaved with a razor.

The client is positioned to minimize pressure on the skin.

The client is covered with a cooling blanket during surgery.

Answer and Explanation

The Correct Answer is C

A. The grounding pad is positioned near the surgical site.: The grounding pad (for electrocautery) should be placed over a large, well-vascularized muscle mass, away from the surgical site and bony prominences.

B. The client's surgical site is shaved with a razor.: Razors create "micro-cuts" that increase the risk of surgical site infections. Clippers are preferred if hair removal is necessary.

C. The client is positioned to minimize pressure on the skin.: During surgery, clients are unable to move or feel pain. Proper padding and positioning are essential to prevent pressure injuries and nerve damage.

D. The client is covered with a cooling blanket.: Maintaining normothermia (normal body temperature) is critical for healing and preventing infection; warming blankets are typically used.

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Correct Answer is A

Explanation

A. Determine the client's ability to use a communication board.: Expressive aphasia affects the ability to produce language. A communication board allows the client to point to pictures or words, facilitating two-way communication during the teaching process.

B. Provide the teaching without expecting the client to respond.: The nurse must evaluate the client’s understanding (the "teach-back" method) to ensure the information was grasped, even if the response is non-verbal.

C. Avoid the use of facial gestures during the instructions.: Non-verbal cues, gestures, and facial expressions are essential tools to help a client with aphasia understand the context of what is being said.

D. Speak with a loud voice while providing the information.: Aphasia is a language processing disorder, not a hearing impairment. Speaking loudly is unnecessary and can be perceived as patronizing.

A. The client has poorly fitting dentures. B. The client is sedentary throughout most of the day. C. The client has no living family. D. The client verbalizes regret about never marrying.

Correct Answer is A

Explanation

A. The client has poorly fitting dentures.: Using the Maslow’s Hierarchy of Needs or the ABC (Airway, Breathing, Circulation) framework, physiological needs are the priority. Poorly fitting dentures lead to impaired nutrition and a risk of choking or aspiration, which is a physical safety threat.

B. The client is sedentary throughout most of the day.: While a sedentary lifestyle increases the risk of pressure injuries and muscle atrophy, it is not as immediate a threat as potential nutritional deficit or airway obstruction.

C. The client has no living family.: This is a psychosocial concern. While it increases the risk for social isolation, it is secondary to physical health needs.

D. The client verbalizes regret about never marrying.: This is an emotional/psychosocial finding related to Erikson’s stage of "Integrity vs. Despair," but it is not the priority over physiological stability.

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A nurse is assisting in the care of a client during surgery. Which of the following should the nurse identify as supporting a safe, therapeutic environment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to reinforce teaching with a client who has expressive aphasia. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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