A nurse is caring for a client in the operating room.
Which of the following interventions is the priority to perform prior to surgery in order to prevent surgical errors in the operating room?
Educate the client about expectations.
Introduce the client to the surgical team.
Obtain vital signs.
Initiate a time-out.
The Correct Answer is D
Choice A rationale
Educating the client about expectations is an important part of the perioperative process to reduce anxiety and improve postoperative outcomes. However, this usually occurs during the preoperative phase before the client enters the operating room. While communication is vital, it does not serve as a primary safety check to prevent technical surgical errors such as wrong site or wrong procedure surgery. In the hierarchy of safety interventions within the operating room, the time out procedure takes precedence over general education.
Choice B rationale
Introducing the client to the surgical team helps establish rapport and can decrease patient stress. While this promotes a culture of communication, it is not a standardized safety protocol designed to prevent surgical errors. Team introductions are part of the initial greeting but do not replace the rigorous verification steps required by surgical safety checklists. The priority in the operating room must be focused on the systematic verification of the patient identity and the intended surgical site.
Choice C rationale
Obtaining vital signs is a fundamental nursing task to assess the physiological stability of the client before anesthesia induction. Normal ranges include a heart rate of 60 to 100 beats per minute and blood pressure around 120 over 80 mmHg. While critical for monitoring the patient's physical condition, taking vitals does not directly prevent errors like operating on the wrong limb. It is a secondary assessment compared to the specific safety protocols meant to ensure the correct surgery is performed.
Choice D rationale
Initiating a time out is the priority intervention to prevent surgical errors. This is a mandatory pause where the entire surgical team verifies the correct patient, correct site, and correct procedure immediately before the incision. This protocol is a standard of care established by The Joint Commission to eliminate "never events" like wrong site surgery. By involving the surgeon, anesthesiologist, and nursing staff in a verbal confirmation, it ensures everyone is in agreement and significantly reduces the risk of error.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Hypoglycemia occurs when blood glucose levels fall below 70 mg/dL, and a level of 42 mg/dL is critically low. This client exhibits classic neuroglycopenic symptoms, including confusion, drowsiness, and irritability, alongside adrenergic signs like diaphoresis. Glipizide, a sulfonylurea, stimulates insulin secretion regardless of glucose levels, which often leads to prolonged hypoglycemia in patients with poor oral intake. Her age and reduced intake over two days significantly increased her risk for this specific metabolic crisis.
Choice B rationale
Diabetic ketoacidosis is characterized by extreme hyperglycemia, typically over 250 mg/dL, along with metabolic acidosis and ketone production. Patients usually present with Kussmaul respirations, a fruity breath odor, and dehydration. This patient’s blood glucose is 42 mg/dL, which is the opposite of the high levels seen in DKA. While confusion can occur in DKA due to acidosis, the low glucose reading and history of glipizide use point directly toward hypoglycemia rather than a state of insulin deficiency.
Choice C rationale
While confusion and irritability can be signs of a stroke, the rapid onset of symptoms in the presence of a known diabetic taking glipizide makes a metabolic cause more likely. Stroke symptoms are usually focal, such as one-sided weakness or facial drooping, which are not described here. Furthermore, the blood glucose reading of 42 mg/dL is an objective finding that explains her neurological status perfectly. It is standard practice to rule out hypoglycemia before diagnosing a stroke.
Choice D rationale
Hyperosmolar Hyperglycemic State is a complication of type 2 diabetes marked by severe hyperglycemia, often exceeding 600 mg/dL, and profound dehydration without significant ketosis. This client’s blood glucose of 42 mg/dL is far below the threshold for HHS. While HHS can cause altered mental status and confusion due to high serum osmolality, this patient’s presentation is dominated by the physiological effects of a sugar deficit, not the osmotic diuresis and high sugar levels characteristic of HHS.
Correct Answer is B
Explanation
Choice A rationale
Ulcerative colitis is a chronic inflammatory bowel disease characterized by inflammation and ulceration of the colon mucosa, usually presenting with frequent bloody diarrhea and abdominal pain. While it can cause abdominal discomfort, it does not typically present as a sudden, acute absence of bowel sounds and flatus in a postoperative context. The clinical manifestations described in the scenario are more indicative of a mechanical or functional obstruction rather than an underlying chronic inflammatory autoimmune condition.
Choice B rationale
A paralytic ileus is a common postoperative complication where intestinal peristalsis stops, often due to abdominal surgery, handling of the intestines, or the effects of anesthesia and opioids. The lack of movement leads to the accumulation of gas and secretions, resulting in an absence of bowel sounds, abdominal distention, and the inability to pass flatus. This functional obstruction is the most likely cause given the timing of three days post-surgery and the specific clinical symptoms provided.
Choice C rationale
Wound dehiscence refers to the partial or total separation of the layers of a surgical wound. While it is a serious postoperative complication, it is characterized by the visible opening of the incision site or the drainage of serosanguineous fluid. It does not directly cause the cessation of bowel sounds or the systemic absence of flatus. Although a severe dehiscence could lead to evisceration and secondary bowel issues, it is not the primary cause of the symptoms described.
Choice D rationale
Cholecystitis is the inflammation of the gallbladder, usually caused by gallstones obstructing the cystic duct. It typically presents with sharp pain in the right upper quadrant of the abdomen, fever, and nausea, often triggered by fatty meals. While abdominal pain occurs, cholecystitis does not cause a generalized cessation of bowel sounds and flatus across the entire intestinal tract. The signs of distention and lack of flatus specifically point toward a functional motility issue in the intestines.
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