A nurse is caring for a client who is scheduled for a procedure. Which of the following actions should the nurse take during the time-out?
(Select All that Apply.)
Ask the client to read their identification bracelet.
Ask the client to point to the surgical site.
Use two acceptable client identifiers.
Verify that the surgical site has been marked.
Ask the client to state the surgery being performed.
Correct Answer : C
A. Asking the client to read their identification bracelet can be additional verification steps, but it is not standard practice for all institutions
B. To point to the surgical site can be additional verification steps, but it is not standard practice for all institutions.
C. Using two acceptable client identifiers, such as the client's name and date of birth, to confirm the patient's identity.
D. It is important to verify that the surgical site has been marked, which is a critical step in preventing wrong-site surgery.
E. Asking the client to state the surgery being performed is a good practice as it involves the patient in their care and serves as a final verification of the correct procedure.
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Related Questions
Correct Answer is B
Explanation
A. Deep breathing exercises should be performed regularly, regardless of the level of pain. The exercises are crucial for preventing lung complications, and pain management should be addressed so that the client can perform these exercises effectively.
B. This statement reflects a proper understanding of the importance of regular deep breathing exercises. Performing these exercises every hour while awake helps to keep the alveoli open and reduces the risk of atelectasis and pneumonia. Consistent practice is essential for maximizing lung expansion and preventing complications.
C. Coughing exercises should be performed regularly, not just when experiencing shortness of breath. Coughing helps to clear secretions from the airways and prevent their accumulation, which can lead to respiratory infections and other complications.
D. Avoiding deep breathing exercises is not advisable. While there may be some discomfort, deep breathing is essential for lung health post-operatively. The exercises help prevent complications such as atelectasis.
Correct Answer is B
Explanation
A. Hyperventilation can lead to dizziness and lightheadedness, and it's not a recommended method for preventing atelectasis.
B. This statement indicates understanding of the importance of deep breathing exercises in preventing atelectasis.
C. This statement shows a misunderstanding of atelectasis. Anyone can develop atelectasis, especially after surgery.
D. This statement is incorrect, but it focuses on treatment rather than prevention.
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