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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is A
Explanation
Choice A reason: Place a black tag on the client’s upper body and attempt to help the next client in need:
In mass casualty incidents, triage is used to prioritize treatment based on the severity of injuries and the likelihood of survival. A black tag indicates that the victim is deceased or has injuries that are not compatible with life and that resources should be directed to those who have a better chance of survival. Since the client remains apneic even after repositioning the airway, it indicates that they are not breathing and have a very low chance of survival.
Choice B reason: Reposition the client’s upper airway a second time before assessing his respirations:
While ensuring the airway is open is crucial, if the client remains apneic after the initial repositioning, further attempts are unlikely to be successful in a mass casualty scenario where time and resources are limited2. The priority is to move on to other victims who may have a higher chance of survival.
Choice C reason: Start CPR:
In a mass casualty situation, CPR is typically not initiated for victims who are apneic and pulseless due to the need to allocate resources to those who have a higher likelihood of survival3. The focus is on providing immediate care to those who can benefit the most from it.
Choice D reason: Place a red tag on the client’s upper body and obtain immediate help from other personnel:
A red tag is used for victims who require immediate life-saving interventions and have a high chance of survival if treated promptly4. Since the client is apneic and remains so after airway repositioning, they do not meet the criteria for a red tag.
Correct Answer is C
Explanation
Choice A: Exophthalmos
Exophthalmos, or bulging eyes, is not a typical symptom of hypothyroidism. Instead, it is commonly associated with hyperthyroidism, particularly Graves’ disease. In hypothyroidism, the thyroid gland is underactive, leading to a different set of symptoms.
Choice B: Photophobia
Photophobia, or sensitivity to light, is not a common symptom of hypothyroidism. While hypothyroidism can cause a variety of symptoms, photophobia is more often associated with conditions affecting the eyes or the nervous system.
Choice C: Lethargy
Lethargy, or extreme fatigue, is a common symptom of hypothyroidism. When the thyroid gland does not produce enough thyroid hormones, the body’s metabolism slows down, leading to feelings of tiredness and lack of energy. This is one of the hallmark symptoms of hypothyroidism and can significantly impact a person’s daily life.
Choice D: Weight Loss
Weight loss is not typically associated with hypothyroidism. In fact, weight gain is more common due to the slowed metabolism caused by an underactive thyroid. Individuals with hypothyroidism often experience difficulty losing weight and may gain weight even with a normal diet and exercise routine.