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.

Answer and Explanation

The Correct Answer is D

Choice A reason: Assessing for discomfort is important, but it is not a safety intervention that should be implemented during the creation of a sterile field.

Choice B reason: Instructing the client to keep hands under the sterile field is not practical or safe, especially since the client is mildly confused and may not be able to follow such instructions.

Choice C reason: Pouring cleansing solution onto the sterile cloth field is part of the debridement process but does not directly relate to client safety.

Choice D reason: Verifying informed consent is crucial for client safety to ensure that the client understands the procedure and agrees to it, especially when the client is confused.

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Correct Answer is C

Explanation

Choice A reason: Asking for specifics about the night nurse's behavior could reinforce negative perceptions and does not address the client's current emotional state.

Choice B reason: Promising to talk to the night nurse may validate the client's split perception without verifying the facts.

Choice C reason: Expressing happiness for the client's improvement and discharge focuses on positive aspects and avoids engaging in potentially manipulative behavior.

Choice D reason: Acknowledging a preference for certain nurses can reinforce the client's splitting behavior, which is unhelpful in managing borderline personality disorder.

A. Obtain a clean, voided urine specimen for analysis. B. Evaluate the client's response to bladder training efforts. C. Provide protective undergarments for the client. D. Encourage increased fluid intake for 24 hours.

Correct Answer is A

Explanation

Choice A reason: Obtaining a urine specimen is essential for analyzing possible infections or other abnormalities that could be causing urinary incontinence.

Choice B reason: While evaluating the client's response to bladder training is important, it is not the first step before diagnosing the cause of new-onset incontinence.

Choice C reason: Providing protective undergarments may help manage symptoms but does not address the underlying cause of the incontinence.

Choice D reason: Encouraging increased fluid intake could potentially exacerbate incontinence symptoms and is not a diagnostic intervention.

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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

Correct Answer is C

Explanation

An older adult client arrives at the clinic describing a new onset of urinary incontinence. Which intervention should the nurse implement?

Correct Answer is A

Explanation

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