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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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

Aspiration: The client reports food getting stuck in the mouth and has a hoarse voice, which are classic signs of dysphagia (difficulty swallowing). Dysphagia significantly increases the risk for aspiration, where food or liquid enters the airway instead of the esophagus.
Neurological status: The client also has left-sided weakness, suggesting a neurologic impairment (possibly from a stroke or similar event), which can affect swallowing coordination and airway protection.

A. Syringe B. Tongue depressor C. Adhesive tape D. Cotton-tipped applicator

Correct Answer is A

Explanation

A. Syringe: A syringe is essential for irrigating a stage 4 pressure injury to cleanse the wound thoroughly without causing trauma to the tissue. Proper irrigation helps remove debris and bacteria, promoting healing. A syringe allows controlled, gentle flushing of the wound bed, which is important in managing deep, complex wounds like stage 4 pressure injuries.

B. Tongue depressor: A tongue depressor is generally used to examine the throat and oral cavity and is not suitable for wound care. It lacks the precision and safety needed for wound cleaning or dressing application, especially for deep pressure ulcers.

C. Adhesive tape: Adhesive tape is used to secure dressings but is not a primary supply for wound care itself. In managing a stage 4 pressure injury, the priority is proper wound cleaning and dressing materials rather than just securing them, so adhesive tape is secondary.

D. Cotton-tipped applicator: Cotton-tipped applicators are commonly avoided in wound care because they can leave fibers in the wound bed and potentially cause trauma or infection. They are not recommended for cleaning or applying medication to deep pressure ulcers, where more sterile, gentle methods are needed.

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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 in a rehabilitation facility is assisting in the care of a client who was admitted the previous day. Exhibits Complete the following sentence by using the list of options. The client is at risk for dropdown as evidenced by the client's dropdown.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

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Explanation

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