During a therapy session, a client begins to cry while discussing a traumatic experience. What is the nurse’s most appropriate response?

Choice A rationale
Providing an opportunity for team members to ask questions is important for effective communication and teamwork, but it is not the primary action to verify the correct patient, procedure, and surgery. This action is more related to ensuring that all team members are on the same page and can clarify any doubts, but it does not directly verify the patient’s identity and procedure.
Choice B rationale
Discussing personal matters unrelated to the surgery is incorrect and unprofessional. It does not contribute to verifying the correct patient, procedure, and surgery. This action can lead to distractions and potential errors in patient care.
Choice C rationale
Reviewing the surgical instruments and equipment is important for ensuring that the necessary tools are available and functioning properly, but it does not directly verify the patient’s identity and procedure. This action is more related to the preparation and readiness of the surgical team.
Choice D rationale
Confirming the patient’s identity and procedure is the correct action to verify the correct patient, procedure, and surgery. This involves verifying the patient’s identity using at least two identifiers, confirming the procedure with the patient or their representative, and ensuring that the correct procedure is on the schedule. This step is crucial to prevent wrong-site, wrong- procedure, and wrong-patient surgeries.

Choice A rationale
Feeding a stroke client who has difficulty in swallowing is a task that requires careful attention to prevent aspiration and choking. While this task is important, it can be delegated to a trained nursing assistant or a licensed practical nurse (LPN) under the supervision of an RN. The RN should focus on tasks that require higher levels of clinical judgment and expertise.
Choice B rationale
Completing a sterile dressing change to a pressure ulcer is a task that requires the expertise and clinical judgment of an RN. Sterile dressing changes involve maintaining a sterile field, assessing the wound, and applying appropriate dressings. This task is critical for preventing infection and promoting wound healing, making it appropriate for the RN to perform.
Choice C rationale
Reapplying a condom catheter for a client with urinary incontinence is a routine procedure that can be delegated to a trained nursing assistant or an LPN. This task does not require the advanced clinical skills and judgment of an RN, allowing the RN to focus on more complex and critical tasks.
Choice D rationale
Reinforcing teaching with a client who is learning how to administer insulin is an important task, but it can be delegated to an LPN under the supervision of an RN. The RN should prioritize tasks that require higher levels of clinical expertise and judgment, such as sterile dressing changes and complex assessments.