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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
A. Abdominal distension is not typically associated with hypokalemia.
B. Often described as pins and needles, this is a common symptom of hypokalemia.
C. Specifically, the appearance of a U wave is a characteristic sign of hypokalemia.
D. Potassium is essential for muscle function, so low levels can lead to weakness.
E. Peak T wave on EKG is associated with hyperkalemia, not hypokalemia.
Correct Answer is D
Explanation
A. Metabolic acidosis is characterized by a primary decrease in bicarbonate (HCO₃⁻) levels, which is not typically a direct result of COPD. However, if a patient with COPD has an additional condition like kidney failure or severe sepsis, they could potentially develop metabolic acidosis. But, this is not the primary concern in COPD.
B. Respiratory alkalosis is caused by hyperventilation, where there is excessive loss of CO₂ leading to an increase in blood pH. This is less common in COPD patients, as they typically have difficulty exhaling CO₂ rather than hyperventilating.
C. Metabolic alkalosis involves an increase in blood pH due to elevated bicarbonate levels or loss of acid. This is not typically associated with COPD, unless there is an unrelated condition causing metabolic alkalosis.
D. COPD is characterized by impaired airflow and reduced ability to expel carbon dioxide (CO₂) effectively. As CO₂ accumulates in the blood, it combines with water to form carbonic acid, which lowers the blood pH, leading to respiratory acidosis.
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