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","C","E"]

Explanation

A. Photo identification: In many long-term care settings, a photo is used as a secondary identifier for clients who may be confused or non-verbal.

B. Room number: Room numbers are never used as identifiers because clients can be moved or transferred between rooms.

C. Facility-assigned identification number: This is a unique number assigned to the specific client upon admission.

D. Diagnosis: Multiple clients on a unit may share the same diagnosis (e.g., CHF or Diabetes).

E. Date of birth: This is a standard, unique identifier used in conjunction with the client's name.

A. "Take a 1-hour nap each day." B. "Watch television in bed." C. "Drink a glass of milk before bedtime." D. "Take a long walk before bedtime."

Correct Answer is C

Explanation

A. "Take a 1-hour nap each day.": Napping during the day, especially for an hour, can interfere with the ability to fall asleep and stay asleep at night.

B. "Watch television in bed.": The bed should be used only for sleep and intimacy. Watching TV provides "blue light" and mental stimulation that disrupts the circadian rhythm.

C. "Drink a glass of milk before bedtime.": Milk contains L-tryptophan, an amino acid that serves as a precursor to serotonin and melatonin, which helps induce sleep.

D. "Take a long walk before bedtime.": Vigorous exercise shortly before bed increases core body temperature and heart rate, which can make falling asleep more difficult.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is preparing to administer medications to a group of clients. Which of the following are acceptable client identifiers for the nurse to use? (Select all that apply.)

Correct Answer is ["A","C","E"]

Explanation

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Correct Answer is C

Explanation

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