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 is positioned to minimize pressure on the skin.

The client is covered with a cooling blanket during surgery.

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

Answer and Explanation

The Correct Answer is B

A. The grounding pad is positioned near the client's surgical site: The grounding pad for electrosurgery should be placed on a large, well-vascularized muscle mass away from the surgical site to ensure proper dispersion of electrical current and prevent burns. Placing it near the site increases risk of injury.

B. The client is positioned to minimize pressure on the skin: Proper positioning during surgery helps prevent pressure ulcers and nerve injuries by reducing prolonged pressure on bony prominences and delicate tissues, supporting a safe and therapeutic environment.

C. The client is covered with a cooling blanket during surgery: Maintaining normothermia is critical; cooling blankets can cause hypothermia, which increases the risk of complications such as infection and coagulopathy. Warm blankets or forced-air warming devices are preferred.

D. The client's surgical site is shaved with a razor: Shaving with a razor can cause microabrasions that increase the risk of surgical site infections. Clipping hair with electric clippers is the recommended practice to reduce infection risk.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Bear weight on the unaffected leg: In a three-point gait, the client bears weight only on the unaffected leg while advancing both crutches and the affected leg together. This gait pattern is used when one leg is non-weight-bearing or injured, ensuring safety and stability during ambulation.

B. Stand with the crutch tips against the feet: Crutch tips should be positioned about 6 inches to the side and slightly in front of the feet to provide a stable base of support. Placing crutches directly against the feet increases the risk of slipping and instability.

C. Hold the arms straight when walking: Arms should be slightly flexed at the elbows when holding crutches to absorb shock and reduce strain. Holding the arms straight can cause fatigue and reduce control during walking.

D. Keep the crutches at the level of the axillae: Crutches should be adjusted to about 1 to 2 inches (2.5 to 5 cm) below the axillae to prevent pressure on the nerves and blood vessels in the armpits, which could cause nerve damage or circulatory problems.

A. "I will keep the drainage bag below the level of my waist." B. "I will apply antiseptic ointment to the tip of my penis." C. "I will empty my drainage bag once a day." D. "I will clamp the tube when I go for a walk."

Correct Answer is A

Explanation

A. "I will keep the drainage bag below the level of my waist.": Keeping the drainage bag below the waist or bladder level is essential to prevent backflow of urine, which can lead to infection or bladder distention. This practice promotes proper drainage by gravity and helps reduce the risk of urinary tract infections.

B. "I will apply antiseptic ointment to the tip of my penis.": Applying antiseptic ointment is generally not recommended unless specifically prescribed by a healthcare provider. Routine use of ointments can irritate the urethral area or disrupt normal flora, potentially increasing infection risk.

C. "I will empty my drainage bag once a day.": Emptying the drainage bag only once daily is insufficient and increases the risk of urinary stasis and infection. The bag should be emptied regularly, at least every 8 hours or when it is two-thirds full, to maintain proper flow and reduce bacterial growth.

D. "I will clamp the tube when I go for a walk.": Clamping the catheter tubing can cause urine retention and increase the risk of bladder overdistention and infection. The tubing should remain open to allow continuous drainage regardless of activity level to ensure bladder emptying and prevent complications.

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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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