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 A
Explanation
A. Alcohol can affect blood clotting mechanisms and increase the risk of bleeding. Chronic alcohol consumption is associated with liver dysfunction, which impairs the production of clotting factors, leading to an increased risk of bleeding during and after surgery.
B. Alcohol consumption does not decrease the risk of postoperative infection. In fact, alcohol use, especially if it’s chronic, can impair the immune system and delay wound healing, potentially increasing the risk of postoperative infections.
C. Alcohol does not enhance the effectiveness of anesthesia; rather, it can complicate anesthesia management. Alcohol can interact with anesthetic agents, potentially altering their effects, leading to unpredictable outcomes.
D. Alcohol does not reduce the risk of postoperative nausea and vomiting (PONV). In fact, alcohol use can exacerbate nausea and vomiting, particularly when combined with anesthetic agents.
Correct Answer is C
Explanation
A. The correct actions to take include staying with the client for the first 15-30 minutes after starting the transfusion, not just the first 10 minutes, to monitor for any adverse reactions.
B. It is also crucial to use 0.9% sodium chloride solution, not 5% dextrose in water, to flush the transfusion tubing.
C. It is a standard practice to have two nurses check the blood unit label to verify the correct blood type and compatibility before administration.
D. The transfusion should not be rushed over 1 hour; instead, it should be administered over a period of 2-4 hours, depending on the patient's condition and the volume of PRBCs to be transfused.
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