A nurse is caring for a client who is scheduled to have surgery. In preparing the client for surgery, which of the following actions is considered outside the nurse’s responsibilities?
Explaining the procedure, risks, and benefits
Reviewing preoperative instructions
Obtaining test results
Ensuring that a signed surgical consent form was completed
Assessing the current health status of the client
The Correct Answer is A
Choice A reason: Explaining the procedure, risks, and benefits
Explaining the surgical procedure, including its risks and benefits, is primarily the responsibility of the surgeon. This is because the surgeon has the detailed knowledge and expertise regarding the specific procedure and can provide comprehensive information to the patient. The nurse’s role in this context is to support the patient by clarifying any information provided by the surgeon and ensuring that the patient understands the instructions. Nurses can also address any immediate concerns or questions the patient might have, but the detailed explanation of the procedure itself is outside their scope of practice.
Choice B reason: Reviewing preoperative instructions
Reviewing preoperative instructions is within the nurse’s responsibilities. Nurses play a crucial role in ensuring that patients understand and follow preoperative instructions, which may include fasting guidelines, medication adjustments, and other preparatory steps. This helps to minimize surgical risks and ensures that the patient is adequately prepared for the procedure. By reviewing these instructions, nurses help to reinforce the information provided by the surgical team and ensure patient compliance.
Choice C reason: Obtaining test results
Obtaining and reviewing test results is also within the nurse’s scope of practice. Nurses are responsible for ensuring that all necessary preoperative tests have been completed and that the results are available for the surgical team. This includes coordinating with the laboratory and other departments to obtain timely results and reviewing them to identify any potential issues that need to be addressed before surgery. This step is critical in ensuring patient safety and readiness for the procedure.
Choice D reason: Ensuring that a signed surgical consent form was completed
Ensuring that a signed surgical consent form is completed is a shared responsibility between the nurse and the surgeon. While the surgeon is responsible for obtaining informed consent by explaining the procedure, risks, and benefits, the nurse’s role is to verify that the consent form has been signed and documented appropriately. This verification process is crucial to ensure that the patient has given informed consent before proceeding with the surgery.
Choice E reason: Assessing the current health status of the client
Assessing the current health status of the client is a fundamental responsibility of the nurse. This involves conducting a thorough health assessment, including taking vital signs, reviewing the patient’s medical history, and identifying any potential risks or concerns that may affect the surgery. This assessment helps to establish a baseline for the patient’s condition and ensures that any necessary precautions are taken to promote a safe surgical outcome.
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Related Questions
Correct Answer is D
Explanation
Choice A reason:
Administer 50,000 units of heparin by IV bolus every 12 hours: This dosage is incorrect and potentially dangerous. Heparin dosing must be carefully calculated based on the patient’s weight and coagulation test results. Standard practice involves adjusting the dose according to the aPTT levels to maintain therapeutic anticoagulation.
Choice B reason:
Have vitamin K available on the nursing unit: Vitamin K is the antidote for warfarin, not heparin. The antidote for heparin is protamine sulfate. Having the correct antidote available is crucial for managing potential bleeding complications associated with heparin therapy.
Choice C reason:
Use tubing specific for heparin sodium when administering the infusion: While it is important to use appropriate tubing for any IV medication, there is no specific tubing required exclusively for heparin sodium. Standard IV tubing is typically sufficient.
Choice D reason:
Check the activated partial thromboplastin time (aPTT) every 6 hours: This is correct. Monitoring aPTT levels is essential when administering a continuous heparin infusion. The aPTT test measures the time it takes for blood to clot and helps ensure that the heparin dose is within the therapeutic range. Regular monitoring helps prevent both under- and over-anticoagulation, reducing the risk of clotting or bleeding complications.
Correct Answer is B
Explanation
Choice A reason:
Restricting the client’s oral fluid intake is not appropriate in this situation. Adequate fluid intake is essential to help flush out the bladder and prevent clot formation. Clients are usually encouraged to drink plenty of fluids to ensure proper hydration and urine flow.
Choice B reason:
Reminding the client that he might feel a constant urge to void is important. After a transurethral resection of the prostate (TURP), the presence of the catheter and continuous bladder irrigation can cause a sensation of needing to urinate. This is a common experience and reassuring the client helps manage their expectations and reduce anxiety.
Choice C reason:
Weighing the client every evening is not a standard intervention specifically related to TURP and continuous bladder irrigation. While monitoring weight can be important for overall health, it is not directly related to the immediate postoperative care of a TURP patient.
Choice D reason:
Monitoring the client’s urine output every 6 hours is important, but it should be done more frequently in the immediate postoperative period. Continuous bladder irrigation requires close monitoring to ensure that the irrigation fluid is flowing properly and that there are no blockages or complications.
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