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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: Offering supplemental formula feedings may not be the best initial approach for inverted nipples as it could lead to nipple confusion and interfere with breastfeeding.

Choice B reason: While teaching about the use of a breast pump is helpful for expressing milk, it does not directly address the issue of latching with inverted nipples.

Choice C reason: A breast shield can be beneficial for mothers with inverted nipples as it can help draw out the nipple, allowing the baby to latch on more effectively.

Choice D reason: Using ice on the areola is not a recommended practice for addressing inverted nipples as it can cause discomfort and is not a reliable method for improving latch.

A. Ask the client to describe the pain. B. Observe body language and movement. C. Identify effective pain relief measures. D. Provide a numeric pain scale.

Correct Answer is A

Explanation

Choice A reason: Asking the client to describe the pain is essential as it provides subjective information about the pain's quality, intensity, and impact on daily activities, which is crucial for assessing osteoarthritis pain.

Choice B reason: Observing body language and movement can offer insights into the pain's impact on function, but it does not replace the client's verbal description of the pain experience.

Choice C reason: Identifying effective pain relief measures is part of managing osteoarthritis but does not directly assess the quality of the client's knee pain.

Choice D reason: Providing a numeric pain scale is a method to quantify pain intensity but may not fully capture the quality or characteristics of the pain.

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

A client who is one day postpartum reports that her baby cannot latch onto the breast. The nurse observes that the client's nipples are inverted. Which action should the nurse implement?

Correct Answer is C

Explanation

The nurse is caring for an older adult client with a history of osteoarthritis who is having difficulty walking due to increased right knee pain. To assess the quality of the client's knee pain, which approach should the nurse use?

Correct Answer is A

Explanation

An older adult client arrives at the clinic describing a new onset of urinary incontinence. Which intervention should the nurse implement?

Patient Data Exhibits The nurse reviews the assessment findings along with the physician orders. Which immediate interventions would the nurse initiate? Select all that apply.

A client arrives for an annual physical exam and reports having calf pain. The client's health history includes peripheral arterial disease. Which question should the nurse ask the client about expected findings related to chronic arterial symptoms?

A client with 50% full-thickness burns has received fluid resuscitation for the past 24 hours. Which assessment warrants immediate intervention by the nurse?

Patient Data Exhibits The nurse reviews the client data. What increases the client's chance for positive outcomes after the completion of the bariatric surgery? Select all that apply.

Patient Data Exhibits Which interventions are indicated to promote positive outcomes for the patient? Select all that apply.

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

When admitting a client with a diagnosis of transient ischemic attack (TIA), which intervention is most important for the nurse to include in this client's plan of care?