The nurse is 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 the procedure is completed.
Instruct the client to keep hands under the sterile field.
Pour cleansing solution onto the sterile cloth field.
Verify that the client has given informed consent.
The Correct Answer is B
Choice A reason: Waiting until after the procedure to assess for discomfort does not ensure client safety during the procedure itself. While pain assessment is important, it is not the priority safety intervention in this situation, especially since the client is already mildly confused and could disrupt the sterile field or injure themselves if not properly guided.
Choice B reason: Because the client is mildly confused, there is a risk of them inadvertently reaching into or touching the sterile field during the procedure. The nurse’s priority safety action is to provide clear, simple instructions such as reminding the client to keep their hands away or under the sterile field. This prevents contamination and reduces the risk of infection, protecting both the client and the procedure.
Choice C reason: Pouring cleansing solution onto the sterile cloth field would contaminate the sterile setup, since fluids should only be poured into sterile containers or basins. This action could compromise the sterile field and increase infection risk, making it unsafe practice.
Choice D reason: Informed consent for a procedure like wound debridement must be obtained by the healthcare provider before the procedure begins, not during. While the nurse can verify consent earlier, at the point described in the scenario (when the sterile field is already set up), the immediate priority is to maintain sterility and safety, not obtain consent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
Choice A reason: Sloughing tissue around wound edges may require debridement but does not typically require immediate intervention unless there is a significant change in the wound's condition.
Choice B reason: Loss of sensation could indicate nerve damage or developing compartment syndrome, which is a medical emergency requiring immediate intervention to prevent permanent damage.
Choice C reason: Weeping serosanguineous fluid is expected in burn wounds and does not necessarily require immediate intervention unless there is a significant increase in output or other signs of infection.
Choice D reason: Increased pain and pressure are signs of potential compartment syndrome or infection, both of which require prompt assessment and possible intervention.
Choice E reason: A change in the quality of peripheral pulses may indicate vascular compromise, which requires immediate intervention to restore circulation and prevent tissue death.
Correct Answer is C
Explanation
Choice A reason: Suggesting that delirium is often a sign of underlying mental illness and that institutionalization is necessary can be distressing and may not be accurate without further assessment.
Choice B reason: Stating that dementia due to Alzheimer's disease is often reversible even in the late stages is incorrect; Alzheimer's disease is a progressive condition with no current cure.
Choice C reason: Recognizing the possibility of delirium due to depression, which can be reversible, is a hopeful and constructive approach that encourages further evaluation and treatment options.
Choice D reason: Suggesting that symptoms of dementia are permanent because of age can be disheartening and does not consider the potential for reversible causes of cognitive impairment.
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