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.
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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Related Questions
Correct Answer is D
Explanation
A. Place cold packs on the client's axillae.: This is an aggressive cooling measure usually reserved for extremely high temperatures (heatstroke) and can cause shivering, which increases metabolic demand.
B. Give the client an alcohol sponge bath.: This is contraindicated as alcohol evaporates too quickly, causing chilling and shivering, and can be absorbed through the skin.
C. Place a fan to blow air across the client.: This can cause shivering, which actually raises the body's internal temperature.
D. Remove blankets from the client.: Removing excess clothing and linens allows for heat loss through radiation and conduction, helping to lower the temperature naturally and comfortably.
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}
Explanation
Correct answer: The client is at risk for Aspiration as evidenced by the client's Dysphagia.
i. Aspiration: The client is exhibiting classic signs of dysphagia (difficulty swallowing), specifically "feeling food stuck in their mouth" and a "hoarse vocal quality." When a client cannot swallow effectively, food or liquid can enter the airway instead of the esophagus, leading to aspiration pneumonia.
ii. Dysphagia: This is the clinical term for the symptoms described in the Nurses' Notes (hoarseness and food pocketing). While the client does have a slightly elevated blood pressure and heart rate, these are secondary to the primary safety risk of an impaired airway/swallow reflex.
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