While preparing a client for surgery, the nurse marks the arm that is to be amputated and participates in a “time-out” procedure before the surgery begins.
Which sentinel event is this action intended to prevent?

The lack of healing of the stump.

Ineffective control of the client’s pain.

The removal of the wrong arm.

The client being mildly sedated.

Answer and Explanation

The Correct Answer is C

This action is intended to prevent a sentinel event, which is a patient safety event that results in death, permanent harm, or severe temporary harm. A sentinel event is a serious adverse event that signals the need for immediate investigation and response. Removing the wrong arm would be a devastating and irreversible outcome for the patient and the health care provider.

Choice A is wrong because the lack of healing of the stump is not a sentinel event. It is a possible complication of amputation that may be related to the natural course of the patient’s illness or underlying condition.

Choice B is wrong because ineffective control of the client’s pain is not a sentinel event. It is a quality of care issue that may affect the patient’s comfort and recovery, but it does not result in death, permanent harm, or severe temporary harm.

Choice D is wrong because the client being mildly sedated is not a sentinel event. It is a level of anesthesia that may be appropriate for some types of surgery, but it does not result in death, permanent harm, or severe temporary harm.

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Correct Answer is D

Explanation

Replacing wet clothing with dry clothing is an independent nursing intervention that can help prevent further heat loss and gradually warm the patient. Soaking extremities in hot water (choice A) is not recommended because it can cause vasodilation and hypotension. Administering warmed intravenous fluids (choice B) and administering hot whirlpool therapy (choice C) are not independent nursing interventions because they require a physician’s order. They are also not appropriate for mild to moderate hypothermia because they can cause rapid rewarming and cardiac dysrhythmias.

A. Decreased blood pressure. B. Bronchial airway constriction. C. Hypoglycemia. D. Dilated pupils.

Correct Answer is D

Explanation

This is because the fight-or-flight response activates the sympathetic nervous system, which causes the pupils to dilate to allow more light and improve vision.

Choice A is wrong because the fight-or-flight response increases blood pressure by constricting blood vessels and increasing heart rate.

Choice B is wrong because the fight-or-flight response causes bronchial airway dilation to allow more oxygen intake and facilitate breathing.

Choice C is wrong because the fight-or-flight response causes hyperglycemia by stimulating the release of glucose from the liver and muscles to provide energy.

Normal ranges for blood pressure are 90/60 mmHg to 120/80 mmHg, for blood glucose are 70 mg/dL to 100 mg/dL, and for pupil size are 2 mm to 6 mm.

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While preparing a client for surgery, the nurse marks the arm that is to be amputated and participates in a “time-out” procedure before the surgery begins. Which sentinel event is this action intended to prevent?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Your patient was outdoors and developed hypothermia. You know that independent nursing interventions would include:

Correct Answer is D

Explanation

A nurse is assisting with teaching a class about physical manifestations associated with the fight-or-flight response to stress. Which of the following manifestations should the nurse include?

Correct Answer is D

Explanation

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While preparing a client for surgery, the nurse marks the arm that is to be amputated and participates in a “time-out” procedure before the surgery begins.
Which sentinel event is this action intended to prevent?