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 A
Explanation
Choice A: Obtain a 12-lead ECG
Obtaining a 12-lead ECG is a critical action when a client has a potassium level of 6.8 mEq/L, which indicates hyperkalemia. Hyperkalemia can cause serious cardiac dysrhythmias, including life-threatening arrhythmias such as ventricular fibrillation or asystole. An ECG can help detect these abnormalities early, allowing for prompt intervention to prevent cardiac complications. The ECG may show characteristic changes such as peaked T waves, widened QRS complexes, and prolonged PR intervals, which are indicative of hyperkalemia.
Choice B: Suggest that the client use a salt substitute
Suggesting that the client use a salt substitute is not appropriate in this situation. Many salt substitutes contain potassium chloride, which can further increase the potassium level in the blood. For a client with hyperkalemia, it is crucial to avoid additional sources of potassium to prevent exacerbating the condition. Therefore, recommending a salt substitute could be harmful.
Choice C: Advise the client to add citrus juices and bananas to her diet
Advising the client to add citrus juices and bananas to her diet is also inappropriate. Both citrus juices and bananas are high in potassium and can contribute to an increase in serum potassium levels. For a client with hyperkalemia, it is essential to limit dietary potassium intake to help lower the potassium levels in the blood. Encouraging the consumption of high-potassium foods would be counterproductive and potentially dangerous.
Choice D: Obtain a blood sample for a serum sodium level
While obtaining a blood sample for a serum sodium level can be part of a comprehensive assessment, it is not the immediate priority in managing hyperkalemia. The primary concern with a potassium level of 6.8 mEq/L is the risk of cardiac dysrhythmias. Therefore, obtaining an ECG to monitor the heart’s electrical activity is the most urgent and appropriate action. Once the immediate risk is addressed, further laboratory tests, including serum sodium levels, can be conducted as part of the overall assessment and management plan.
Correct Answer is A
Explanation
Choice A reason:
Metoprolol is a beta-blocker commonly used to treat high blood pressure (hypertension). One of its primary therapeutic effects is the reduction of blood pressure. By blocking beta-adrenergic receptors, metoprolol decreases the heart rate and the force of contraction, leading to lower blood pressure.
Choice B reason:
While metoprolol can help manage certain types of dysrhythmias by slowing the heart rate and stabilizing the heart’s rhythm, the primary therapeutic effect for which it is most commonly prescribed is the reduction of blood pressure.
Choice C reason:
Increased urine output is not a direct therapeutic effect of metoprolol. This effect is more commonly associated with diuretics, which are often used in conjunction with beta-blockers to manage hypertension and heart failure.
Choice D reason:
Decreased pulse is a potential effect of metoprolol, as it slows the heart rate. However, this is not the primary therapeutic goal. The main therapeutic effect is the reduction of blood pressure.