A charge nurse is assessing the room of a newly admitted client who has dysphagia. Which of the following pieces of equipment should the nurse ensure is available in the client's room?

Choice A Reason:
Gauze is used to clean the wound from the outside to the center. This action does not demonstrate safe handling techniques. Wound cleaning should generally proceed from the least contaminated area to the most contaminated area, which is usually from the center of the wound outward, to avoid introducing microorganisms into the wound.
Choice B Reason:
The soiled dressing is placed on a nearby table. Placing the soiled dressing on a nearby table poses a risk of contamination to the surrounding environment and is not considered a safe practice. Soiled dressings should be properly disposed of in a designated biohazard waste container.
Choice C Reason:
This action demonstrates an understanding of infection control. Clean gloves should be discarded after removing the old dressing to prevent transferring any contaminants to the new dressing or sterile supplies.
Choice D Reason:
Sterile supplies should be opened only after the old dressing has been removed and the wound area has been cleaned.

Choice A Reason:
Telling the client that their blood alcohol level will be checked is incorrect. Threatening the client with other forms of testing may not be ethically or legally appropriate, especially if the client has refused the initial request. It's important to respect the client's autonomy and right to refuse testing.
Choice B Reason:
Informing the client that a catheter will be inserted is incorrect. Inserting a catheter against the client's will is invasive and would constitute a violation of the client's autonomy and bodily integrity. It is not an appropriate action.
Choice C Reason:
Documenting the client's refusal in their chart is correct. Documenting the client's refusal is essential for accurate record-keeping and ensures that the healthcare team is aware of the client's decision. It also helps protect the nurse and the healthcare facility in case of any legal or ethical challenges related to the client's refusal.
Choice D Reason:
Assessing the client for urinary retention is incorrect. While urinary retention may be a concern in some cases, it is not the immediate action to take when a client refuses to provide a urine sample. The priority is to respect the client's autonomy and document their refusal appropriately. If there are clinical indications or concerns about urinary retention, they can be assessed separately and addressed accordingly.