The nurse 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?
Explanation & Rationale
Rationale: A. Assess for discomfort when procedure is completed: Pain assessment is important after the procedure, but it does not address intra-procedural safety. Preventing disruption of the sterile field during the procedure takes priority in this moment. B. Verify that the client has given informed consent: While consent is essential, it should be obtained before starting the procedure. If the debridement is already underway, verifying consent is no longer the immediate focus for ensuring safety. C. Instruct the client to keep hands under the sterile field: A mildly confused client may unintentionally contaminate the sterile field. Providing clear instructions to keep hands away helps preserve sterility and reduces the risk of infection. D. Pour cleansing solution onto the sterile cloth field: Pouring solution directly onto the sterile cloth can compromise the integrity of the sterile field. Cleansing solutions should be poured into sterile containers, not directly on the field, to maintain proper technique.