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 A

Explanation

A. "I will keep the drainage bag below the level of my waist.": Keeping the drainage bag below the waist or bladder level is essential to prevent backflow of urine, which can lead to infection or bladder distention. This practice promotes proper drainage by gravity and helps reduce the risk of urinary tract infections.

B. "I will apply antiseptic ointment to the tip of my penis.": Applying antiseptic ointment is generally not recommended unless specifically prescribed by a healthcare provider. Routine use of ointments can irritate the urethral area or disrupt normal flora, potentially increasing infection risk.

C. "I will empty my drainage bag once a day.": Emptying the drainage bag only once daily is insufficient and increases the risk of urinary stasis and infection. The bag should be emptied regularly, at least every 8 hours or when it is two-thirds full, to maintain proper flow and reduce bacterial growth.

D. "I will clamp the tube when I go for a walk.": Clamping the catheter tubing can cause urine retention and increase the risk of bladder overdistention and infection. The tubing should remain open to allow continuous drainage regardless of activity level to ensure bladder emptying and prevent complications.

A. Oriented to person only B. Hearing acuity intact C. Ability to use call light D. Full range of motion bilateral lower extremities

Correct Answer is A

Explanation

A. Oriented to person only indicates the client is confused about time, place, or situation, which increases the risk of injury due to impaired judgment and decreased awareness of surroundings. This cognitive impairment can lead to unsafe behaviors like attempting to get out of bed unassisted or wandering.

B. Hearing acuity intact helps the client receive verbal instructions and alarms, reducing injury risk by facilitating communication and timely responses to safety cues. Good hearing supports situational awareness, which is protective against accidents.

C. Ability to use call light allows the client to summon assistance when needed, helping prevent falls or other injuries. This functional independence in communication is a key safety factor in the acute care setting.

D. Full range of motion in bilateral lower extremities indicates good physical mobility and strength, which decreases injury risk by enabling the client to reposition safely and maintain balance during transfers or ambulation.

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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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