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. 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.

A. Speak with a loud voice while providing the information. B. Determine the client's ability to use a communication board. C. Provide the teaching without expecting the client to respond. D. Avoid the use of facial gestures during the instructions.

Correct Answer is B

Explanation

A. Speak with a loud voice while providing the information: Increasing the volume of speech is not effective for clients with expressive aphasia because their difficulty lies in producing language, not hearing. Speaking loudly may cause frustration or discomfort without improving communication.

B. Determine the client's ability to use a communication board: Assessing the client’s ability to use a communication board is an essential strategy to facilitate effective communication. Augmentative tools like communication boards can help them convey their needs and participate in teaching.

C. Provide the teaching without expecting the client to respond: Teaching without expecting any response can lead to missed opportunities for interaction and engagement. Encouraging some form of response, even nonverbal or through assistive devices, helps evaluate the client’s comprehension and maintains their involvement.

D. Avoid the use of facial gestures during the instructions: Facial gestures, body language, and visual cues play an important role in enhancing communication for clients with aphasia. Using expressive gestures should be encouraged to supplement verbal teaching and promote better comprehension.

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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 collecting data from a client who has a stage 4 pressure injury. Which of the following supplies should the nurse obtain?

Correct Answer is A

Explanation

A nurse is preparing to reinforce teaching with a client who has expressive aphasia. Which of the following actions should the nurse plan to take?

Correct Answer is B

Explanation

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