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 is positioned to minimize pressure on the skin.

The client is covered with a cooling blanket during surgery.

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

Answer and Explanation

The Correct Answer is B

A. The grounding pad is positioned near the client's surgical site: The grounding pad for electrosurgery should be placed on a large, well-vascularized muscle mass away from the surgical site to ensure proper dispersion of electrical current and prevent burns. Placing it near the site increases risk of injury.

B. The client is positioned to minimize pressure on the skin: Proper positioning during surgery helps prevent pressure ulcers and nerve injuries by reducing prolonged pressure on bony prominences and delicate tissues, supporting a safe and therapeutic environment.

C. The client is covered with a cooling blanket during surgery: Maintaining normothermia is critical; cooling blankets can cause hypothermia, which increases the risk of complications such as infection and coagulopathy. Warm blankets or forced-air warming devices are preferred.

D. The client's surgical site is shaved with a razor: Shaving with a razor can cause microabrasions that increase the risk of surgical site infections. Clipping hair with electric clippers is the recommended practice to reduce infection risk.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Leave the needle in place for 10 seconds after the injection: Leaving the needle in place for approximately 10 seconds after administering a subcutaneous injection helps ensure full delivery of the medication and reduces the chance of medication leakage at the injection site.

B. Use a 5-inch needle for the injection: A 5-inch needle is excessively long for subcutaneous injections and would likely penetrate muscle tissue, increasing the risk of injury or incorrect medication administration. Subcutaneous injections typically require a needle length between ⅜ and ⅝ inch.

C. Inject the medication using the Z-track technique: The Z-track technique is used for intramuscular injections to minimize medication leakage and reduce irritation. It is not appropriate for subcutaneous injections, which are administered into the fatty layer beneath the skin, not deep muscle tissue.

D. Insert the syringe at a 15° angle during injection: A 15° angle is used for intradermal injections. Subcutaneous injections should be administered at a 45° to 90° angle depending on the client’s body mass to ensure the medication is delivered into the subcutaneous tissue, not the dermis or muscle.

A. Wait for 4 hr before sending the specimen to the laboratory. B. Avoid collecting the specimen from areas of the stool that contain blood. C. Transfer the specimen to a cup without it touching the outside of the container. D. Collect at least 7.62 cm (3 in) of the client's stool.

Correct Answer is C

Explanation

A. Wait for 4 hr before sending the specimen to the laboratory: Delaying the transport of stool specimens can affect test results by allowing bacterial growth or degradation of components. Specimens should be sent promptly or refrigerated if there is a delay.

B. Avoid collecting the specimen from areas of the stool that contain blood: If testing for occult blood or infection, areas with blood should be included because they provide important diagnostic information, so avoiding them is incorrect.

C. Transfer the specimen to a cup without it touching the outside of the container: Maintaining specimen integrity and preventing contamination is essential. The nurse should ensure the stool does not contact the outside of the container to avoid spreading pathogens and ensure accurate testing.

D. Collect at least 7.62 cm (3 in) of the client's stool: Collecting such a large amount is unnecessary; usually a smaller amount (about 1 inch or walnut size) is sufficient for testing, so this choice is incorrect.

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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 administer a subcutaneous injection to a client. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is preparing to collect a stool specimen from a client for laboratory testing. Which of the following actions should the nurse take when collecting the specimen?

Correct Answer is C

Explanation

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