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 B

Explanation

A) Simvastatin: Simvastatin is a medication used to lower cholesterol levels and does not typically require monitoring of blood pressure before or after administration. While statins may have some indirect cardiovascular benefits, blood pressure is not directly affected by this medication, so it is not necessary to assess blood pressure before or after administering simvastatin.

B) Metoprolol: This is the correct answer. Metoprolol is a beta-blocker commonly used to treat hypertension and other cardiovascular conditions. It works by reducing heart rate and blood pressure. Therefore, it is important to assess the client's blood pressure both before and after administering metoprolol to ensure the medication is having the desired effect and to detect any adverse changes, such as hypotension or bradycardia.

C) Acetylsalicylic Acid (Aspirin): Aspirin is primarily used for its antiplatelet effect, such as for preventing heart attacks or strokes, and it does not have a significant direct impact on blood pressure. While aspirin can have side effects, such as gastrointestinal irritation or bleeding, blood pressure monitoring is generally not necessary before or after administering aspirin.

D) Metformin: Metformin is used to manage type 2 diabetes by helping control blood glucose levels. It does not directly affect blood pressure, so routine blood pressure assessment is not required before or after giving metformin. However, monitoring for side effects like gastrointestinal distress or lactic acidosis is important, but blood pressure is not a priority for this medication.

A. An area of non-blanchable redness on inner skin B. An open wound with visible adipose tissue C. An area of shallow broken skin with blistering D. Deep purple discoloration over intact skin

Correct Answer is C

Explanation

A. An area of non-blanchable redness on inner skin:
A stage II pressure injury is characterized by partial-thickness skin loss involving the epidermis and/or dermis. It may present as a shallow, open wound or blister. However, non-blanchable redness, which suggests a stage I pressure injury, is not consistent with stage II, as stage II involves more significant skin damage, including blistering or broken skin.

B. An open wound with visible adipose tissue:
This description is more characteristic of a stage III pressure injury, which involves full-thickness skin loss extending into the subcutaneous tissue, revealing adipose tissue. Stage II pressure injuries, on the other hand, are partial-thickness and do not expose underlying structures such as adipose tissue.

C. An area of shallow broken skin with blistering:
Stage II pressure injuries are defined by partial-thickness skin loss, which can present as a shallow open wound or blister. This description accurately fits the characteristics of a stage II pressure injury, where the skin is damaged but the full-thickness layers are not yet compromised.

D. Deep purple discoloration over intact skin:
This is indicative of a stage I pressure injury, which involves intact skin with non-blanchable redness or discoloration. Stage II injuries involve skin breakdown and would not present with intact skin or deep purple discoloration. This description is more aligned with the early stages of pressure injury development, not stage II.

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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?

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