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.
The Correct Answer is B
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: Because the client is mildly confused, there is a risk of them inadvertently reaching into or touching the sterile field during the procedure. The nurse’s priority safety action is to provide clear, simple instructions such as reminding the client to keep their hands away or under the sterile field. This prevents contamination and reduces the risk of infection, protecting both the client and the procedure.
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: Informed consent for a procedure like wound debridement must be obtained by the healthcare provider before the procedure begins, not during. While the nurse can verify consent earlier, at the point described in the scenario (when the sterile field is already set up), the immediate priority is to maintain sterility and safety, not obtain consent.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Encouraging the client to lie still during the assessment is not advisable as it does not provide an accurate representation of the client's functional abilities and needs during rehabilitation.
Choice B reason: While understanding episodes of sundowning can be part of a comprehensive assessment, it is not the action the nurse should implement during a functional assessment aimed at determining the client's physical capabilities.
Choice C reason: Assisting with values clarification about end-of-life care options is important but is not the primary focus of a functional assessment in a rehabilitation setting.
Choice D reason: Questioning the client about the frequency of falls is crucial as it helps assess the risk of future falls and the need for interventions to prevent them, which is a key component of functional assessments in rehabilitation settings.
Correct Answer is ["2.4"]
Explanation
Step 1: Convert the weight from pounds to kilograms. We know that 1 kg = 2.2 lbs. So, the weight in kg is:
175 lbs ÷ 2.2 = 79.55 kg
Step 2: Calculate the total units of heparin needed. The prescription is for 3 units/kg, so:
3 units/kg × 79.55 kg = 238.65 units
Step 3: Calculate the volume of heparin to administer. The vial is labeled as "100 units/mL", so:
238.65 units ÷ 100 units/mL = 2.39 mL
So, the nurse should administer approximately 2.4 mL of heparin (rounded to the nearest tenth).
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