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 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.

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Correct Answer is B

Explanation

Choice A reason: A blood pressure of 130/80 mm Hg is considered high normal and may not require immediate follow-up for a patient with a history of hypertension.

Choice B reason: A serum creatinine of 1.6 mg/dL is above the normal range for both males and females, indicating possible kidney dysfunction, which requires further follow-up.

Choice C reason: Dark yellow urine could be a sign of dehydration, which is common in diabetes, but it is not as concerning as an elevated serum creatinine level.

Choice D reason: Difficulty staying asleep could be related to various factors and may require follow-up, but it is not as urgent as abnormal laboratory values.

Correct Answer is ["2.4"]

Explanation

Step 1: Convert the weight from pounds to kilograms. We know that 1 kg = 2.2 lbs. So, the weight in kg is:

175 lbs ÷ 2.2 = 79.55 kg

Step 2: Calculate the total units of heparin needed. The prescription is for 3 units/kg, so:

3 units/kg × 79.55 kg = 238.65 units

Step 3: Calculate the volume of heparin to administer. The vial is labeled as "100 units/mL", so:

238.65 units ÷ 100 units/mL = 2.39 mL

So, the nurse should administer approximately 2.4 mL of heparin (rounded to the nearest tenth).

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The healthcare provider has prescribed heparin, 3 units/kg to be administered via IV push for a client who weighs 175 pounds. The vial is labeled as "100 units/mL." How many mL should the nurse administer? (Please enter the numerical value only. If rounding is required, round to the nearest tenth.)

Correct Answer is ["2.4"]

Explanation

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