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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Correct Answer is D
Explanation
A. Lymphocytes are a type of white blood cell that plays a crucial role in the immune system, specifically in the response to infections and in immune regulation. They do not have a role in the transport of oxygen in the blood.
B. Neutrophils are another type of white blood cell that is essential for fighting bacterial infections. They are part of the body's immune response but do not transport oxygen.
C. Platelets are small cell fragments that are crucial for blood clotting and wound repair. They do not have a role in oxygen transport.
D. Hemoglobin is the primary molecule responsible for transporting oxygen in the blood. It is a protein found in red blood cells (erythrocytes) that binds to oxygen in the lungs and releases it in tissues throughout the body. Hemoglobin carries the majority of oxygen in the bloodstream and is essential for effective oxygen transport and delivery.
Correct Answer is C
Explanation
A. Changing the patient's head position during suctioning can increase discomfort and hypoxia.
B. This is premature. The tachycardia may be a temporary response to the suctioning procedure.
C. The increased heart rate is likely a response to the stimulation of suctioning. Stopping the procedure allows the patient to recover and reassessment can determine if further suctioning is necessary.
D. This is excessive and not necessary at this time.
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