The nurse is caring for a patient who will be having surgery shortly. The patient requests that a religious bracelet be worn in the operating room to help ensure a good surgical outcome. Which is the most appropriate action of the nurse?
Insist that the patient remove the bracelet and give it to a family member during surgery.
Notify the patient’s surgeon of the patient’s refusal to remove the bracelet before having surgery.
Call the operating room staff to determine if the bracelet can stay on during surgery.
Remove the bracelet from the patient's wrist after sedating medication has been administered.
The Correct Answer is C
Choice A reason: This is an incorrect choice because insisting that the patient remove the bracelet and give it to a family member during surgery is not the most appropriate action of the nurse. This action may violate the patient's right to autonomy, religious freedom, and cultural sensitivity. The nurse should respect the patient's beliefs and preferences and try to accommodate them as much as possible, unless they pose a significant risk to the patient's safety or the surgical procedure.
Choice B reason: This is an incorrect choice because notifying the patient’s surgeon of the patient’s refusal to remove the bracelet before having surgery is not the most appropriate action of the nurse. This action may imply that the patient is non-compliant or difficult, and may create a conflict between the patient and the surgeon. The nurse should communicate with the patient and the surgeon in a respectful and collaborative manner, and seek a mutually agreeable solution.
Choice C reason: This is the correct choice because calling the operating room staff to determine if the bracelet can stay on during surgery is the most appropriate action of the nurse. This action shows that the nurse is willing to advocate for the patient and to consult with the relevant authorities to find out the best option. The nurse should follow the policies and protocols of the operating room and the infection control guidelines, and ensure that the bracelet does not interfere with the surgical site, the equipment, or the sterile field.
Choice D reason: This is an incorrect choice because removing the bracelet from the patient's wrist after sedating medication has been administered is not the most appropriate action of the nurse. This action may be considered unethical, dishonest, or disrespectful, as the nurse is taking advantage of the patient's altered mental status and going against the patient's wishes. The nurse should obtain the patient's informed consent before performing any intervention, and should not deceive or coerce the patient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is an incorrect choice because powerlessness related to inability to keep from eating during sleep is not the highest priority nursing diagnosis for a patient who developed sleep-related eating disorder when taking Zolpidem. Powerlessness is a psychosocial problem that affects the patient's sense of control and self-efficacy. However, it is not the most urgent or life-threatening problem for the patient, as it does not pose an immediate risk of harm or injury.
Choice B reason: This is an incorrect choice because wandering related to cognitive impairment from sleeping aid is not the highest priority nursing diagnosis for a patient who developed sleep-related eating disorder when taking Zolpidem. Wandering is a behavioral problem that involves moving about aimlessly or without purpose. However, it is not the most urgent or life-threatening problem for the patient, as it does not necessarily imply a risk of harm or injury.
Choice C reason: This is the correct choice because risk for falls related to ambulating to kitchen while asleep is the highest priority nursing diagnosis for a patient who developed sleep-related eating disorder when taking Zolpidem. Risk for falls is a safety problem that involves an increased likelihood of falling due to factors such as impaired balance, coordination, or judgment. This is the most urgent and life-threatening problem for the patient, as it can result in serious injuries or complications.
Choice D reason: This is an incorrect choice because risk for imbalanced nutrition: more than body requirements related to sleep eating is not the highest priority nursing diagnosis for a patient who developed sleep-related eating disorder when taking Zolpidem. Risk for imbalanced nutrition: more than body requirements is a physiological problem that involves an intake of nutrients that exceeds metabolic needs. However, it is not the most urgent or life-threatening problem for the patient, as it does not cause an immediate risk of harm or injury.
Correct Answer is C
Explanation
Choice A reason: This is an incorrect choice because professional shared governance is not a patient care action, but an organizational model that empowers nurses and other health care professionals to participate in decision making and policy development within their practice settings.
Choice B reason: This is an incorrect choice because nursing care delivery model is not a patient care action, but a framework that defines how nursing care is organized, coordinated, and delivered to the patients. Examples of nursing care delivery models include primary nursing, team nursing, and case management.
Choice C reason: This is the correct choice because interprofessional communication is a patient care action that involves exchanging information, ideas, and feedback among health care professionals from different disciplines who work together to provide comprehensive care for the patients. Interprofessional communication enhances collaboration, quality, and safety of care.
Choice D reason: This is an incorrect choice because continuing staff education is not a patient care action, but a professional development activity that involves updating and enhancing the knowledge and skills of the health care staff through formal or informal learning opportunities. Continuing staff education improves the competence and performance of the staff.
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