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.

Answer and Explanation

The Correct Answer is D

Choice A reason: Assessing for discomfort is important, but it is not a safety intervention that should be implemented during the creation of a sterile field.

Choice B reason: Instructing the client to keep hands under the sterile field is not practical or safe, especially since the client is mildly confused and may not be able to follow such instructions.

Choice C reason: Pouring cleansing solution onto the sterile cloth field is part of the debridement process but does not directly relate to client safety.

Choice D reason: Verifying informed consent is crucial for client safety to ensure that the client understands the procedure and agrees to it, especially when the client is confused.

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Correct Answer is C

Explanation

Choice A reason: Reporting any change in urine color is important but not specific to the provision of palliative care at home.

Choice B reason: Maintaining in high Fowler's position is not always necessary and may not be comfortable for all clients, especially in a palliative care setting.

Choice C reason: Keeping mucous membranes moist helps prevent discomfort and is a key part of providing compassionate end-of-life care.

Choice D reason: Recording the client's daily weights is less relevant in palliative care, where the focus is on comfort rather than ongoing medical assessments.

A. New management's expectations. B. Changes in job descriptions. C. Employees' job security. D. Potential changes in employee benefits.

Correct Answer is C

Explanation

Choice A reason: While new management's expectations are important, they are not as immediate a concern as job security during restructuring.

Choice B reason: Changes in job descriptions can be a concern, but they are secondary to the more pressing issue of whether employees will retain their jobs.

Choice C reason: Job security is typically the most pressing concern for employees during restructuring, as it directly impacts their livelihood and future with the company.

Choice D reason: Potential changes in employee benefits are important but are generally less immediate than concerns about job security.

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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?

Nursing Test Bank

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Correct Answer is C

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