A nurse is assisting in the care of a client during surgery. Which of the following should the nurse identify as supporting a safe, therapeutic environment?

The grounding pad is positioned near the client's surgical site.

The client's surgical site is shaved with a razor.

The client is positioned to minimize pressure on the skin.

The client is covered with a cooling blanket during surgery.

Answer and Explanation

The Correct Answer is C

A. The grounding pad is positioned near the surgical site.: The grounding pad (for electrocautery) should be placed over a large, well-vascularized muscle mass, away from the surgical site and bony prominences.

B. The client's surgical site is shaved with a razor.: Razors create "micro-cuts" that increase the risk of surgical site infections. Clippers are preferred if hair removal is necessary.

C. The client is positioned to minimize pressure on the skin.: During surgery, clients are unable to move or feel pain. Proper padding and positioning are essential to prevent pressure injuries and nerve damage.

D. The client is covered with a cooling blanket.: Maintaining normothermia (normal body temperature) is critical for healing and preventing infection; warming blankets are typically used.

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Correct Answer is ["A","C","E"]

Explanation

A. Telephone number: A telephone number is a valid and unique personal identifier according to Joint Commission standards.

B. Diagnosis: Multiple clients may have the same diagnosis (e.g., "Pneumonia").

C. Date of birth: This is a standard, universally accepted unique identifier.

D. Room number: Room numbers are not person-specific and can change frequently.

E. Identification bracelet: The ID band contains the client's name and a unique medical record number, making it a primary source for verification.

A. An assistive personnel places a weight-sensitive sensor mat on the mattress beneath a client's buttocks. B. A client who has a transcutaneous electrical nerve stimulation unit reports a buzzing sensation at the application site. C. A client who has bilateral wrist restraints has a capillary refill of less than 2 seconds. D. An assistive personnel raises all four side rails of a client's bed before leaving the room.

Correct Answer is D

Explanation

A. AP places a weight-sensitive sensor mat on the mattress beneath a client's buttocks.: This is a standard fall-prevention intervention and is not a hazard.

B. Client with a TENS unit reports a buzzing sensation.: This is a normal, expected sensation during TENS therapy.

C. Client with bilateral wrist restraints has a capillary refill of < 2 seconds.: This is a positive finding indicating that the restraints are not too tight and circulation is intact.

D. An assistive personnel raises all four side rails: Raising all four side rails is considered a restraint and is a major safety hazard, as it increases the risk of the client trying to climb over them and falling from a greater height.

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A nurse is assisting in the care of a client during surgery. Which of the following should the nurse identify as supporting a safe, therapeutic environment?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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