The nurse is assisting the healthcare provider with a wound debridement at the bedside of a client who is mildly confused. The client is draped and a sterile field is created. Which nursing intervention should the nurse implement for client safety?

Assess for discomfort when the procedure is completed.

Instruct the client to keep hands under the sterile field.

Pour cleansing solution onto the sterile cloth field.

Verify that the client has given informed consent.

None

Answer and Explanation

The Correct Answer is D

Choice A reason: Waiting until after the procedure to assess for discomfort does not ensure client safety during the procedure itself. While pain assessment is important, it is not the priority safety intervention in this situation, especially since the client is already mildly confused and could disrupt the sterile field or injure themselves if not properly guided.

Choice B reason: Instructing a mildly confused client to keep their hands under the sterile field is likely to be ineffective and potentially dangerous. A confused client may not be able to follow or remember complex instructions, increasing the risk of contaminating the sterile field or causing injury. Instead, a nurse or assistant should physically stay near the client's hands to guide them.

Choice C reason: Pouring cleansing solution onto the sterile cloth field would contaminate the sterile setup, since fluids should only be poured into sterile containers or basins. This action could compromise the sterile field and increase infection risk, making it unsafe practice.

Choice D reason: Verification of informed consent is a critical safety intervention that must occur before any invasive procedure. Since the client is mildly confused, the nurse must ensure that the client had the capacity to consent or that a legal proxy provided it. Proceeding without verifying consent is a legal risk and violates the client's autonomy and safety protocols.

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Free Nursing Study Resources

Correct Answer is ["B","C","D","F"]

Explanation

Choice A Reason: Selecting only food items with no fat is not recommended because some fats, particularly unsaturated fats, are beneficial for health and should be included in a balanced diet.
Choice B Reason: Taking a cinnamon supplement may be beneficial as some studies suggest that cinnamon can help lower blood sugar levels and improve insulin sensitivity.
Choice C Reason: Minimizing the number of refined grains in the diet is advised because refined grains can have a negative impact on blood sugar control and may increase the risk of type 2 diabetes.
Choice D Reason: Eliminating sugary beverages and juices from the diet is beneficial as these can lead to spikes in blood sugar levels and contribute to weight gain, which is a risk factor for type 2 diabetes.
Choice E Reason: Doubling the usual amount of protein in the diet is not necessary and could lead to an excessive intake of calories. Protein should be consumed in moderation and as part of a balanced diet.
Choice F Reason: Increasing the amount of dietary fiber is recommended because fiber can help manage blood sugar levels and reduce the risk of developing type 2 diabetes.

A. Activate the lockdown procedure. B. Match ID bands of all infants and mothers on the unit. C. Ask the mother if any visitors were expected to arrive. D. Determine if the newborn is in the nursery.

Correct Answer is A

Explanation

Choice A reason: The immediate activation of the lockdown procedure is critical in the event of a suspected infant abduction, as it helps to secure the facility and prevent the unauthorized removal of the infant.

Choice B reason: Matching ID bands is a standard procedure but not the first action to take in a potential abduction scenario.

Choice C reason: Asking the mother about expected visitors is part of the investigation but does not take precedence over securing the facility.

Choice D reason: Determining if the newborn is in the nursery is important but should follow the immediate security measures.

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The nurse is assisting the healthcare provider with a wound debridement at the bedside of a client who is mildly confused. The client is draped and a sterile field is created. Which nursing intervention should the nurse implement for client safety?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Exhibits Review H and P, nurse's note, and laboratory results. What other nutritional recommendation(s) would be helpful for this client in reducing risk for type 2 diabetes mellitus? Select all that apply.

Correct Answer is ["B","C","D","F"]

Explanation

A new mother on the postpartum unit runs out of the room screaming that her newborn infant's crib is empty and the baby is missing. Which action should the nurse take first?

Correct Answer is A

Explanation

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The nurse is caring for an older adult client with a history of osteoarthritis who is having difficulty walking due to increased right knee pain. To assess the quality of the client's knee pain, which approach should the nurse use?