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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Correct Answer is C

Explanation

A. Hypoactivity: Hypoactive bowel sounds refer to reduced or diminished intestinal activity, often indicating slowed motility. These sounds are usually soft, infrequent, or absent, which contrasts with the loud, growling sounds described in this scenario.

B. Paralytic ileus: Paralytic ileus is a condition characterized by the absence of intestinal motility, resulting in no bowel sounds on auscultation. The presence of loud growling sounds indicates active bowel movements, making paralytic ileus an unlikely term.

C. Borborygmi: Borborygmi describes the loud, rumbling, growling, or gurgling sounds caused by the movement of gas and fluids through the intestines. These sounds are normal but can be louder than usual in cases of increased gastrointestinal activity, such as hunger or diarrhea.

D. Distention: Distention refers to the visible swelling or enlargement of the abdomen, often due to gas, fluid, or mass accumulation. It is a physical finding observed visually or by palpation, not a term for a type of bowel sound heard during auscultation.

A. Chlorine bleach B. Chlorhexidine C. Triclosan D. Isopropyl alcohol

Correct Answer is A

Explanation

A. Chlorine bleach: Chlorine bleach is the recommended disinfectant for cleaning surfaces contaminated with Clostridium difficile spores. It is effective in killing these hardy spores that are resistant to many other disinfectants.

B. Chlorhexidine: Chlorhexidine is an antiseptic commonly used for skin cleansing, not for disinfecting environmental surfaces contaminated with C. difficile. It is ineffective against spores.

C. Triclosan: Triclosan is an antimicrobial found in some personal care products, but it is not suitable or approved for disinfecting surfaces in healthcare settings, especially against C. difficile.

D. Isopropyl alcohol: Alcohol-based disinfectants are ineffective against C. difficile spores. They do not have sporicidal activity and are not recommended for cleaning in cases of C. difficile infection.

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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?

Nursing Test Bank

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