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 D
Explanation
Choice A: A High Concentration of Carbon Monoxide Can Cause Death
This statement is correct. Carbon monoxide (CO) is a colorless, odorless, and tasteless gas that can be deadly at high concentrations. It binds to hemoglobin in the blood more effectively than oxygen, leading to hypoxia (lack of oxygen) in body tissues. High levels of CO can cause severe symptoms such as confusion, loss of consciousness, and death if not treated promptly.
Choice B: I Should Purchase a Carbon Monoxide Detector for My Home
This statement is also correct. Installing a carbon monoxide detector in the home is a crucial safety measure. These detectors can alert individuals to the presence of CO, allowing them to take action before the gas reaches dangerous levels. It is recommended to place detectors near sleeping areas and to test them regularly to ensure they are functioning properly.
Choice C: Breathing in Carbon Monoxide Can Cause Headaches and Nausea
This statement is accurate. Early symptoms of carbon monoxide poisoning include headaches, dizziness, nausea, and fatigue. These symptoms occur because CO interferes with the body’s ability to transport and use oxygen, leading to hypoxia. If exposure continues, symptoms can worsen and lead to more severe health issues.
Choice D: I Can Detect the Presence of Carbon Monoxide by a Metallic Odor
This statement indicates a need for further instruction. Carbon monoxide is odorless, which means it cannot be detected by smell. This is why CO is often referred to as a “silent killer.” Relying on the ability to smell CO is dangerous and ineffective. The only reliable way to detect CO is through the use of a carbon monoxide detector.
Correct Answer is C
Explanation
Choice A: Botulism is Acquired Through Direct Contact with an Infected Person
Botulism is not acquired through direct contact with an infected person. It is caused by a toxin produced by the bacterium Clostridium botulinum. The most common forms of botulism are foodborne, wound, and infant botulism. Foodborne botulism occurs when a person ingests food containing the toxin, while wound botulism occurs when the bacteria infect a wound and produce the toxin. Infant botulism occurs when infants ingest spores of the bacteria, which then grow and produce the toxin in their intestines.
Choice B: Notify the Centers for Disease Control and Prevention (CDC) When More Than Three Cases Are Confirmed
While notifying the CDC is crucial in the event of a botulism outbreak, the specific threshold for notification can vary. Generally, any suspected case of botulism should be reported to public health authorities immediately due to the severity of the disease and the potential for outbreaks. The CDC provides guidelines for reporting and managing botulism cases.
Choice C: Botulism Can Produce Paralysis Within 12 to 72 Hours Following Exposure
Botulism can indeed produce paralysis within 12 to 72 hours following exposure. The toxin affects the nervous system, leading to muscle paralysis. Early symptoms include weakness, dizziness, and dry mouth, followed by more severe symptoms such as blurred vision, difficulty swallowing, and muscle weakness. If left untreated, botulism can lead to respiratory failure and death.
Choice D: Vomiting and Diarrhea Are Expected Findings Following Exposure
Vomiting and diarrhea are not typical symptoms of botulism. The primary symptoms are related to muscle paralysis and neurological impairment. Gastrointestinal symptoms may occur in some cases of foodborne botulism, but they are not the hallmark signs of the disease.
Choice E: Botulism is a Toxin Found in Castor Beans
Botulism is not a toxin found in castor beans. The toxin found in castor beans is ricin, which is a different type of bioterrorism agent. Botulism is caused by the botulinum toxin produced by Clostridium botulinum bacteria.
