A nurse is caring for a client who is scheduled to have surgery. In preparing the client for surgery, which of the following actions is considered outside the nurse’s responsibilities?
Explaining the procedure, risks, and benefits
Reviewing preoperative instructions
Obtaining test results
Ensuring that a signed surgical consent form was completed
Assessing the current health status of the client
The Correct Answer is A
Choice A: Explaining the procedure, risks, and benefits
Explaining the surgical procedure, including its risks and benefits, is primarily the responsibility of the surgeon. This is because the surgeon has the detailed knowledge and expertise regarding the specific procedure and can provide comprehensive information to the patient. The nurse’s role in this context is to support the patient by clarifying any information provided by the surgeon and ensuring that the patient understands the instructions. Nurses can also address any immediate concerns or questions the patient might have, but the detailed explanation of the procedure itself is outside their scope of practice.
Choice B: Reviewing preoperative instructions
Reviewing preoperative instructions is within the nurse’s responsibilities. Nurses play a crucial role in ensuring that patients understand and follow preoperative instructions, which may include fasting guidelines, medication adjustments, and other preparatory steps. This helps to minimize surgical risks and ensures that the patient is adequately prepared for the procedure. By reviewing these instructions, nurses help to reinforce the information provided by the surgical team and ensure patient compliance.
Choice C: Obtaining test results
Obtaining and reviewing test results is also within the nurse’s scope of practice. Nurses are responsible for ensuring that all necessary preoperative tests have been completed and that the results are available for the surgical team. This includes coordinating with the laboratory and other departments to obtain timely results and reviewing them to identify any potential issues that need to be addressed before surgery. This step is critical in ensuring patient safety and readiness for the procedure.
Choice D: Ensuring that a signed surgical consent form was completed
Ensuring that a signed surgical consent form is completed is a shared responsibility between the nurse and the surgeon. While the surgeon is responsible for obtaining informed consent by explaining the procedure, risks, and benefits, the nurse’s role is to verify that the consent form has been signed and documented appropriately. This verification process is crucial to ensure that the patient has given informed consent before proceeding with the surgery.
Choice E: Assessing the current health status of the client
Assessing the current health status of the client is a fundamental responsibility of the nurse. This involves conducting a thorough health assessment, including taking vital signs, reviewing the patient’s medical history, and identifying any potential risks or concerns that may affect the surgery. This assessment helps to establish a baseline for the patient’s condition and ensures that any necessary precautions are taken to promote a safe surgical outcome.
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Correct Answer is ["C","E"]
Explanation
Choice A: Plan a plan of care for a client when postoperative from an appendectomy
Planning a plan of care for a client, especially postoperatively, is a complex task that requires comprehensive assessment and critical thinking skills. This responsibility typically falls within the scope of practice of a registered nurse (RN) rather than an LPN. The RN is trained to develop individualized care plans based on a thorough assessment of the client’s condition, medical history, and specific needs. This ensures that the care plan is holistic and addresses all aspects of the client’s recovery.
Choice B: Provide discharge instructions to a confused client’s spouse
Providing discharge instructions, particularly to a confused client’s spouse, involves detailed communication and education. This task is generally performed by an RN, who has the expertise to ensure that the instructions are clear, comprehensive, and tailored to the client’s specific needs. The RN can also assess the spouse’s understanding and provide additional clarification as needed. This ensures that the client receives appropriate care at home and reduces the risk of complications.
Choice C: Administer a tap-water enema to a client who is preoperative
Administering a tap-water enema is a task that can be safely delegated to an LPN. LPNs are trained to perform routine procedures such as enemas, which do not require the advanced assessment skills of an RN. This task involves following established protocols and ensuring the client’s comfort and safety during the procedure. By delegating this task to an LPN, the RN can focus on more complex aspects of client care.
Choice D: Clean vital signs from a client who is 6 hours postoperative
The task of cleaning vital signs is not clearly defined in the context provided. However, if it refers to monitoring and recording vital signs, this is a task that can be delegated to an LPN. LPNs are competent in taking and recording vital signs, which is a routine part of client care. Accurate monitoring of vital signs is essential for assessing the client’s postoperative status and identifying any potential complications.
Choice E: Catheterize a client who has not voided in 8 hours
Catheterization is a procedure that LPNs are trained to perform. This task involves inserting a catheter to relieve urinary retention, which can be a common issue in postoperative clients. LPNs can perform this procedure safely and effectively, following established protocols to minimize the risk of infection and ensure the client’s comfort. Delegating this task to an LPN allows the RN to focus on other critical aspects of client care.
Correct Answer is A
Explanation
Choice A reason:
The Heimlich maneuver, also known as abdominal thrusts, is the recommended first aid technique for a conscious person who is choking. This maneuver helps to expel the object blocking the airway by using the air remaining in the lungs to force it out. The nurse should stand behind the person, place their arms around the person’s waist, make a fist with one hand, and place it just above the navel. The other hand should grasp the fist, and quick, upward thrusts should be performed until the object is expelled.
Choice B reason:
Slapping the client on the back several times is not the recommended first action for a conscious adult who is choking. While back blows can be effective, they are typically used in combination with abdominal thrusts and are more commonly recommended for infants. For adults, the Heimlich maneuver is preferred as the initial response.
Choice C reason:
Assisting the client to the floor and beginning mouth-to-mouth resuscitation is not appropriate for a conscious person who is choking. Mouth-to-mouth resuscitation, or rescue breathing, is used when a person is not breathing and is unresponsive. In this scenario, the client is conscious but unable to speak, indicating a blocked airway that requires the Heimlich maneuver.
Choice D reason:
Observing the client before taking further action is not advisable in a choking emergency. Immediate intervention is crucial to prevent the situation from worsening. If the person is unable to speak, cough, or breathe, the Heimlich maneuver should be performed without delay.
