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.

None

Answer and Explanation

The Correct Answer is D

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: Instructing a mildly confused client to keep their hands under the sterile field is likely to be ineffective and potentially dangerous. A confused client may not be able to follow or remember complex instructions, increasing the risk of contaminating the sterile field or causing injury. Instead, a nurse or assistant should physically stay near the client's hands to guide them.

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: Verification of informed consent is a critical safety intervention that must occur before any invasive procedure. Since the client is mildly confused, the nurse must ensure that the client had the capacity to consent or that a legal proxy provided it. Proceeding without verifying consent is a legal risk and violates the client's autonomy and safety protocols.

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","C","D"]

Explanation

The correct answer is: a, c, d.

Choice A: Avoid prolonged standing or sitting

Reason: Prolonged standing or sitting can exacerbate symptoms of chronic venous insufficiency (CVI) by increasing venous pressure and promoting blood pooling in the legs. Movement helps to enhance venous return and reduce swelling.

Choice B: Cross legs at the knee but not at the ankle

Reason: Crossing legs at the knee can impede blood flow and increase venous pressure, which is counterproductive for managing CVI. It is generally advised to avoid crossing legs at the knee to promote better circulation.

Choice C: Continue wearing compression stockings

Reason: Compression stockings are a cornerstone in the management of CVI. They help to improve venous return, reduce swelling, and prevent blood from pooling in the legs. Compression stockings should be worn as prescribed, typically during the day and removed at night.

Choice D: Use a recliner for long periods of sitting

Reason: Using a recliner can help elevate the legs above heart level, which reduces venous pressure and promotes venous return. This position can help alleviate symptoms of CVI.

Choice E: Maintain the bed flat while sleeping

Reason: Maintaining the bed flat while sleeping is not recommended for CVI management. Elevating the legs while sleeping can help reduce venous pressure and prevent blood from pooling in the legs.

A. Right lower abdominal pain. B. Peripheral neuropathy. C. Confusion. D. Depression.

Correct Answer is C

Explanation

Choice A reason: Right lower abdominal pain is not typically associated with Wernicke's syndrome and would likely indicate a different issue.

Choice B reason: Peripheral neuropathy can be a symptom of Wernicke's syndrome, but it is not as central to the condition as confusion, which is a hallmark sign.

Choice C reason: Confusion is a primary symptom of Wernicke's syndrome and should be used in planning the client's care, as it indicates acute encephalopathy and the need for immediate treatment with thiamine.

Choice D reason: Depression may be present in clients with Wernicke's syndrome, but it is not a primary assessment finding used to plan care for the acute stage of the condition.

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

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

Naxlex Comprehensive Predictor Exams

The home care nurse provided self-care instructions for a client with chronic venous insufficiency caused by deep vein thrombosis. What instruction(s) should the nurse include in the client's discharge teaching plan? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

Choice A: Avoid prolonged standing or sitting

Choice B: Cross legs at the knee but not at the ankle

Choice C: Continue wearing compression stockings

Choice D: Use a recliner for long periods of sitting

Choice E: Maintain the bed flat while sleeping

A client is admitted with the diagnosis of Wernicke's syndrome. Which assessment finding should the nurse use in planning the client's care?

Correct Answer is C

Explanation

Patient Data Exhibits Review H and P, nurse's note, and laboratory results. What other nutritional recommendation(s) would be helpful for this client in reducing risk for type 2 diabetes mellitus? Select all that apply.

A client is being discharged home after being treated for heart failure (HF). Which instruction should the nurse include in this client's discharge teaching plan?

The parent of a child born with a myelomeningocele asks the nurse, "What did I do to deserve this?" Which response is most helpful?

Patient Data: Exhibits Review H and P and laboratory results. Based on the laboratory data, the client has dropdown related to dropdown

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.)

Patient Data Exhibits The nurse educates the parents on post discharge care for the child. What should the nurse include in post discharge care education? Select all that apply.

The nurse observes an unlicensed assistive personnel (UAP) washing hands prior to entering the client's room. Which action by the UAP requires additional teaching?