The nurse is preparing a client for surgery in ine pre-operative setting. Which of the following is not the responsibility of the RN?

Explaining the purpose, risks, benefit, and alternatives of the surgery

Witnessing the client’s signature on the consent form

Conducting a baseline physical assessment and obtaining vital signs

Ensuring the pre-operative checklist is completed

Answer and Explanation

The Correct Answer is A

A) Explaining the purpose, risks, benefit, and alternatives of the surgery: This is not the responsibility of the RN. The role of explaining the purpose, risks, benefits, and alternatives of the surgery falls under the responsibility of the surgeon or the healthcare provider performing the procedure. The RN can provide general information and support but is not responsible for explaining the details of the surgery or obtaining informed consent.

B) Witnessing the client’s signature on the consent form: This is within the RN’s scope of practice. The nurse's role in the consent process is to witness the client's signature, ensuring that it is voluntary and that the client appears to be competent and informed. The nurse does not explain the details of the procedure, but they confirm that the patient has been informed by the surgeon.

C) Conducting a baseline physical assessment and obtaining vital signs: This is an important responsibility of the RN. The nurse conducts a thorough pre-operative assessment, which includes gathering baseline physical data and vital signs. This helps establish a reference point for the client’s health status before surgery and allows for the identification of any abnormalities that may need to be addressed.

D) Ensuring the pre-operative checklist is completed: This is also the RN's responsibility. The nurse ensures that all aspects of the pre-operative checklist, which includes verifying consent, ensuring necessary tests are done, and confirming that the patient is prepared for surgery, are completed. This is part of the nurse’s role in preparing the patient for a safe surgical experience.

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Correct Answer is ["44"]

Explanation

Total volume to infuse: 400 mL

Infusion time: 3 hours

Drop factor of tubing: 20 gtt/mL

To find:

Drip rate (gtt/min)

Step 1: Convert infusion time to minutes

3 hours x 60 minutes/hour = 180 minutes

Step 2: Calculate the total number of drops

Total drops = Total volume x Drop factor

Total drops = 400 mL x 20 gtt/mL = 8000 gtt

Step 3: Calculate the drip rate

Drip rate = Total drops / Infusion time in minutes

Drip rate = 8000 gtt / 180 minutes = 44.44 gtt/min

Step 4: Round to the nearest whole number

44 gtt/min

A. Auscultate the client’s apical pulse for a full minute B. Advise the client that vomiting is primary side effect C. Check the client’s blood pressure D. Obtain a STAT chest X-ray

Correct Answer is C

Explanation

A. Auscultate the client’s apical pulse for a full minute:
While auscultating the apical pulse is important for certain cardiovascular conditions, it is not the primary action needed before administering sublingual nitroglycerin. The nurse's main priority is to assess the patient's blood pressure, as nitroglycerin can cause significant hypotension (a drop in blood pressure), and it is important to ensure the patient’s blood pressure is adequate before administration. If the blood pressure is too low, nitroglycerin should not be given.

B. Advise the client that vomiting is a primary side effect:
Vomiting is not a primary or common side effect of sublingual nitroglycerin. Nitroglycerin is more likely to cause headaches, dizziness, flushing, and hypotension. While it’s helpful to inform the patient about possible side effects, advising them that vomiting is a primary side effect could cause unnecessary concern or confusion.

C. Check the client’s blood pressure:
This is the correct action. Nitroglycerin works by dilating blood vessels, which can lower blood pressure. Before administering sublingual nitroglycerin, it is essential to check the client's blood pressure. If the client is hypotensive or has low blood pressure, nitroglycerin should be withheld, as it could further decrease blood pressure and worsen the patient’s condition. This is the priority nursing action to ensure the patient’s safety.

D. Obtain a STAT chest X-ray:
Obtaining a chest X-ray is not a priority action for a client with unstable angina before administering nitroglycerin. Chest X-rays are more useful for diagnosing conditions like pneumonia, pneumothorax, or other structural issues of the chest, but they are not immediately needed in the management of unstable angina. The most immediate concern is assessing the patient’s blood pressure before administering nitroglycerin.

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The nurse is preparing a client for surgery in ine pre-operative setting. Which of the following is not the responsibility of the RN?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["44"]

Explanation

The nurse is caring who presented with unstable angina. Before giving the client, a dose of sublingual nitroglycerin, which action should the nurse take?

Correct Answer is C

Explanation

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