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
None
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Engaging in non-threatening conversations can help the client feel more comfortable and may encourage communication, which is crucial for clients who are withdrawn due to depression.
Choice B reason: Family visits can be supportive, but the client's withdrawal suggests a need for more direct intervention to encourage communication.
Choice C reason: Scheduling a conference with a social worker is important, but it is not the most immediate intervention for a withdrawn client.
Choice D reason: Group activities may be overwhelming for a client who is noncommunicative and may not be the most suitable initial approach.
Correct Answer is ["A","E"]
Explanation
Choice A reason: Allergic rhinitis is a common condition that responds well to antihistamines, which can alleviate symptoms such as sneezing, runny nose, and itching.
Choice B reason: Otitis media is an inflammation of the middle ear and is not typically treated with antihistamines.
Choice C reason: Myocarditis is an inflammation of the heart muscle and is not treated with antihistamines.
Choice D reason: Bronchitis involves inflammation of the bronchial tubes and is not primarily treated with antihistamines.
Choice E reason: Contact dermatitis, which is an allergic skin reaction, can be treated with antihistamines to relieve itching and rash.
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