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:
Inserting a nasogastric tube is not the first-line intervention for postoperative nausea and vomiting (PONV). This invasive procedure is typically reserved for severe cases where other interventions have failed.
Choice B reason:
Administering an antiemetic is the appropriate action. Antiemetics help control nausea and vomiting, which are common side effects of opioids like morphine. This intervention can provide immediate relief and improve the client’s comfort.
Choice C reason:
Auscultating bowel sounds is important for assessing gastrointestinal function, but it does not directly address the immediate symptom of nausea and vomiting. This assessment can be part of the overall evaluation but is not the primary intervention.
Choice D reason:
Encouraging the client to ambulate is beneficial for overall recovery and can help reduce the risk of complications such as deep vein thrombosis. However, it does not directly address the immediate issue of nausea and vomiting.
Correct Answer is A
Explanation
Choice A: Administer the Medications 5 Minutes Apart
Administering the medications 5 minutes apart is crucial when using multiple eye drops. This practice ensures that each medication has enough time to be absorbed without being washed out by the subsequent drop. This is particularly important for medications like timolol and pilocarpine, which are used to manage intraocular pressure in glaucoma.
Choice B: Hold Pressure on the Conjunctival Sac for 2 Minutes Following Application of Drops
Holding pressure on the conjunctival sac (punctal occlusion) for 2 minutes after applying eye drops can help reduce systemic absorption and increase the local effect of the medication. However, this instruction is not as critical as the timing between administering different eye drops.
Choice C: It Is Not Necessary to Remove Contact Lenses Before Administering Medications
This statement is incorrect. Contact lenses should be removed before administering eye drops to prevent contamination and ensure proper absorption of the medication. The lenses can be reinserted after a sufficient amount of time has passed, usually around 15 minutes.
Choice D: Administer the Medications by Touching the Tip of the Dropper to the Sclera of the Eye
This statement is incorrect. The tip of the dropper should never touch the eye or any other surface to avoid contamination. The correct method is to hold the dropper above the eye and squeeze out the prescribed number of drops into the conjunctival sac.