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 B
Explanation
Choice A reason:
Advising that the largest meal of the day should be in the evening is not typically recommended for clients with a colostomy. It is generally better to have smaller, more frequent meals throughout the day to aid digestion and reduce the risk of discomfort.
Choice B reason:
Eating yogurt can indeed help decrease the amount of gas. Yogurt contains probiotics, which can aid in digestion and reduce gas production. This is a beneficial dietary choice for clients with a colostomy.
Choice C reason:
Carbonated beverages are not recommended for controlling odor. In fact, they can increase gas production and lead to bloating, which can be uncomfortable for clients with a colostomy.
Choice D reason:
There is no need to eliminate pasta from the diet to prevent loose stools. Instead, clients should focus on a balanced diet that includes low-fiber foods initially and gradually reintroduce other foods while monitoring their effects.
Correct Answer is B
Explanation
Choice A reason: Creatinine:
Creatinine is a waste product produced by muscles and is filtered out of the blood by the kidneys. Elevated creatinine levels can indicate kidney dysfunction. However, in this scenario, the primary concern is liver damage due to the combination of alcohol and acetaminophen, making AST a more relevant marker.
Choice B reason:Aspartate aminotransferase (AST):
AST is an enzyme found in the liver and heart. Elevated levels of AST can indicate liver damage. Given the client’s high intake of both alcohol and acetaminophen, there is a significant risk of liver damage. Monitoring AST levels can help assess the extent of liver injury.
Choice C reason:Amylase:
Amylase is an enzyme produced by the pancreas and salivary glands that helps in the digestion of carbohydrates. Elevated amylase levels are typically associated with pancreatic disorders, such as pancreatitis. While important, it is not the priority in this case where liver damage is the main concern.
Choice D reason: Antidiuretic hormone (ADH):
ADH is a hormone that helps regulate water balance in the body by controlling the amount of water reabsorbed by the kidneys. Abnormal levels of ADH can indicate issues with fluid balance, but it is not directly related to liver function or the effects of alcohol and acetaminophen.