A nurse is assisting with a surgical procedure that requires a large number of instruments and supplies. Which of the following strategies should the nurse use to facilitate counting and prevent foreign body retention? (Select all that apply.)

Use a standardized counting method and sequence for each procedure.

Separate sponges into groups of five or ten and count them as one unit.

Keep instruments and supplies on separate trays according to their function.

Use a white board or paper to record the counts and update them as needed.

Discard any unused items before the final count.

Answer and Explanation

Correct Answer : A,B,D

Choice A reason:

Using a standardized counting method and sequence for each procedure helps to ensure consistency and accuracy in the counting process. It also reduces the risk of confusion or miscommunication among the surgical team members. This is a recommended standard of practice by the Association of Surgical Technologists (AST)

Choice B reason:

Separating sponges into groups of five or ten and counting them as one unit helps to facilitate counting and prevent foreign body retention. It also allows for easier identification of missing sponges in case of an incorrect count. This is another recommended standard of practice by the AST.

Choice C reason:

Keeping instruments and supplies on separate trays according to their function does not necessarily facilitate counting or prevent foreign body retention. It may help to organize the surgical field, but it does not address the issue of counting or documenting the items used during the procedure. Therefore, this is not a correct answer.

Choice D reason:

Using a white board or paper to record the counts and update them as needed helps to facilitate counting and prevent foreign body retention. It provides a visual reference for the surgical team members and allows for easy verification of the counts at any time during the procedure. It also helps to document any discrepancies or changes in the counts. This is another recommended standard of practice by the AST.

Choice E reason:

Discarding any unused items before the final count does not facilitate counting or prevent foreign body retention. It may actually increase the risk of losing track of the items used during the procedure or leaving some items inside the patient. Therefore, this is not a correct answer.

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Correct Answer is A

Explanation

Choice A reason:

Compressing the drain reservoir before closing the wound creates a vacuum that helps to suction out the fluid from the wound and prevent infection. This is a common practice for bulb-type drains that apply gentle suction.

Choice B reason:

Securing the drain tubing to the patient's skin with tape is not necessary and may cause skin irritation or damage. The drain tubing can be attached to the patient's clothes with a safety pin or secured near the bandage.

Choice C reason:

Emptying the drain reservoir when it is half full and measuring the output is part of the drain care at home, not during the surgical procedure. The patient or caregiver should empty the drain 2 to 3 times a day (or more), depending on the amount of output, and record it in a chart.

Choice D reason:

Flushing the drain tubing with saline solution every 4 hours is not recommended and may introduce infection or clog the tubing. The tubing should be kept clear by squeezing or "milking”. it occasionally to prevent clots from forming. : Instructions for Surgical Drain Care - Cleveland Clinic : How to Care for Your Surgical Drain at Home - Verywell Health : Surgical Drain Care: Care Instructions | Kaiser Permanente.

A. "You should change your dressing every day and keep it dry.” B. "You can shower with your dressing on, but do not soak it in water.” C. "You should inspect your dressing for signs of infection, such as redness, swelling, or drainage.” D. "You can remove your dressing after 24 hours and leave the wound open to air."

Correct Answer is C

Explanation

Choice A reason:

This is incorrect because changing the dressing every day and keeping it dry may not be appropriate for all types of wounds. Some wounds may require more frequent dressing changes or moist wound healing environment to promote healing and prevent infection.

Choice B reason:

This is incorrect because showering with the dressing on may cause the dressing to become wet and contaminated, which can increase the risk of infection and delay healing. The dressing should be changed before and after showering, and the wound should be protected from water as much as possible.

Choice C reason:

This is correct because inspecting the dressing for signs of infection, such as redness, swelling, or drainage, is an important part of wound care. The patient should be taught how to recognize and report these signs to the health care provider as soon as possible. Early detection and treatment of infection can prevent complications and promote healing.

Choice D reason:

This is incorrect because removing the dressing after 24 hours and leaving the wound open to air may not be advisable for some wounds, especially those that are deep, large, or at risk of infection. The wound may need to be covered with an appropriate dressing for a longer period of time to protect it from contamination, maintain moisture balance, and support healing.

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A nurse is assisting with a surgical procedure that requires a large number of instruments and supplies. Which of the following strategies should the nurse use to facilitate counting and prevent foreign body retention? (Select all that apply.)

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Correct Answer is C

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