The nurse 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 procedure is completed.

Verify that the client has given informed consent.

Instruct the client to keep hands under the sterile field.

Pour cleansing solution onto the sterile cloth field.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Assess for discomfort when procedure is completed: Pain assessment is important after the procedure, but it does not address intra-procedural safety. Preventing disruption of the sterile field during the procedure takes priority in this moment.

B. Verify that the client has given informed consent: While consent is essential, it should be obtained before starting the procedure. If the debridement is already underway, verifying consent is no longer the immediate focus for ensuring safety.

C. Instruct the client to keep hands under the sterile field: A mildly confused client may unintentionally contaminate the sterile field. Providing clear instructions to keep hands away helps preserve sterility and reduces the risk of infection.

D. Pour cleansing solution onto the sterile cloth field: Pouring solution directly onto the sterile cloth can compromise the integrity of the sterile field. Cleansing solutions should be poured into sterile containers, not directly on the field, to maintain proper technique.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:
A. Ask the client to describe the pain: Describing the pain in the client's own words helps determine the pain’s quality, such as whether it's throbbing, stabbing, or dull. This subjective data is critical for diagnosing migraine type. It provides insight into patterns and guides individualized treatment options.

B. Provide a numeric pain scale: The numeric pain scale measures intensity, not quality, of pain. While important, it does not offer specific details on the sensation or nature of the migraine. It is more effective for tracking changes in pain severity over time.

C. Identify effective pain relief measures: This evaluates which interventions are working, not the type of pain being experienced. It is valuable for long-term management but doesn't assist with assessing the sensory qualities of current pain..

D. Observe body language and movement: Observation gives indirect clues about pain presence but not quality. Body language may suggest discomfort, yet it cannot replace verbal descriptions of the pain's nature.

A. Prevent injury. B. Prevent infection. C. Protect skin integrity. D. Manage fluid volume.

Correct Answer is A

Explanation

Rationale:

A. Prevent injury: In CKD, high phosphate and low calcium levels contribute to bone demineralization, increasing fracture risk. Hypocalcemia can also cause muscle cramps and tetany, making fall prevention and safety a priority.

B. Prevent infection: While infection is a general concern in CKD, these specific lab findings do not indicate immunosuppression. The primary issue here relates to bone health and calcium-phosphate imbalance, not immune function.

C. Protect skin integrity: Skin care is important in CKD, especially with pruritus, but it is not the direct consequence of calcium-phosphate imbalance. The immediate risk related to these values is musculoskeletal, not dermatologic.

D. Manage fluid volume: Fluid volume control is essential in CKD but unrelated to phosphate-calcium shifts. These labs reflect mineral and bone metabolism disturbances, not volume overload or deficit.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Focused Assessment Area	Clinical Finding
Musculoskeletal	Ambulates with a walker Flaccidity of left arm Passive range of motion of the left leg
Psychosocial	Fits of laughter Angry outbursts Tearful sharing of stories
Neurological	Drinks with repetitive cough Decorticate posturing Speaks in short sentences

The nurse 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

The nurse is caring for a client who has been admitted with recurring migraine headaches. To assess the quality of the client's pain experienced from the migraine headache, which approach should the nurse use?

Correct Answer is A

Explanation

In caring for a client with chronic kidney disease (CKD), the nurse notes that the client's serum phosphate level is elevated, with a converse decrease in serum calcium. Which nursing care goal is a priority, based on these laboratory findings?

Correct Answer is A

Explanation

While the nurse is conducting an admission assessment of a female client with bipolar disorder, the client suddenly begins to take off her clothes and throw them about the room. Which action should the nurse take first?

Patient Data Exhibits Which intervention(s) should the nurse initiate if elder mistreatment is suspected? Select all that apply.

After administering an antipyretic medication, which intervention should the nurse implement?

A client shares with the nurse concerns of a possible stomach ulcer. The client is experiencing heartburn and a dull gnawing pain that is relieved with eating. Which is the best response by the nurse?

Which dietary intervention(s) should the nurse include in the plan of care for a client who had bariatric surgery? Select all that apply.