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 C
Explanation
A. Gather additional information from the caller to verify their identity.: Even if the identity is verified, the nurse cannot release information without the client’s explicit consent or a pre-established privacy code.
B. Request that the caller contact the client's provider directly.: The provider is also bound by HIPAA and cannot release information to the sibling without consent.
C. Ask the caller to contact the client directly for information.: This protects the client's privacy and ensures that the client remains in control of their own health information.
D. Provide the caller with a brief update.: This is a direct violation of HIPAA regulations regarding client confidentiality.
Correct Answer is C
Explanation
A. "He appears anxious about the transfer.": This is a subjective observation. While helpful, it is not the most critical clinical data point.
B. "He is voiding adequately.": This is vague. A transfer report should include specific data (e.g., "Voided 400 mL of clear yellow urine this shift").
C. "He is allergic to sulfa.": Safety information, particularly allergies, is the most critical information to communicate to the receiving nurse to prevent a life-threatening medication error.
D. "His partner has been visiting.": This is social information and, while helpful for holistic care, is not a priority for a clinical transfer report.
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