A nurse is caring for a client who is scheduled for a procedure. Which of the following actions should the nurse take during the time-out?
(Select All that Apply.)

Ask the client to read their identification bracelet.

Ask the client to point to the surgical site.

Use two acceptable client identifiers.

Verify that the surgical site has been marked.

Ask the client to state the surgery being performed.

Answer and Explanation

Correct Answer : C

A.   Asking the client to read their identification bracelet can be additional verification steps, but it is not standard practice for all institutions

B.   To point to the surgical site can be additional verification steps, but it is not standard practice for all institutions.
C.   Using two acceptable client identifiers, such as the client's name and date of birth, to confirm the patient's identity.
D.   It is important to verify that the surgical site has been marked, which is a critical step in preventing wrong-site surgery.
E.   Asking the client to state the surgery being performed is a good practice as it involves the patient in their care and serves as a final verification of the correct procedure.

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Correct Answer is A

Explanation

A. This helps prevent air leaks and maintains the closed drainage system's function.
B. Looping the tubing on the client's is incorrect as it can lead to inaccurate drainage and measurement of the fluid.
C. Placing the drainage system above the level of the client's heart is incorrect as it can lead to inaccurate drainage and measurement of the fluid.
D. Routine stripping of the chest tube is also not recommended as it can cause trauma to the pleura and potentially lead to complications.

Correct Answer is ["0.8"]

Explanation

(desired dose / available dose) x available quantity.

For this scenario, it would be (100 mg / 250 mg) x 2 mL, which equals 0.8 mL.

Therefore, the nurse should administer 0.8 mL of hydrocortisone per dose to deliver the prescribed 100 mg dosage.

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A nurse is caring for a client who is scheduled for a procedure. Which of the following actions should the nurse take during the time-out? (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a chest tube. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is preparing to administer hydrocortisone 100 mg IM daily to a client. Available is hydrocortisone 250 mg/2 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["0.8"]

Explanation

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A nurse is caring for a client who is scheduled for a procedure. Which of the following actions should the nurse take during the time-out?
(Select All that Apply.)