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 C

Explanation

A. Changing the patient's head position during suctioning can increase discomfort and hypoxia.
B. This is premature. The tachycardia may be a temporary response to the suctioning procedure.
C. The increased heart rate is likely a response to the stimulation of suctioning. Stopping the procedure allows the patient to recover and reassessment can determine if further suctioning is necessary.
D. This is excessive and not necessary at this time.

A. Monitoring the patient's vital signs B. Assessing the patient's pain level C. Inspecting the surgical incision site for redness, swelling D. Assessing the patient's fluid intake and output

Correct Answer is C

Explanation

A. While important for overall patient assessment, it's not the most direct way to monitor for a wound infection.
B. Pain can indicate a wound infection, but it's not as specific as directly inspecting the wound.
C. This is the most direct way to assess for early signs of a wound infection. Redness, swelling, warmth, and drainage are classic signs of infection.
D. Important for overall patient care, but not specifically related to wound infection prevention.

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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.)

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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.)