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.
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Related Questions
Correct Answer is D
Explanation
A. Lymphocytes are a type of white blood cell that plays a crucial role in the immune system, specifically in the response to infections and in immune regulation. They do not have a role in the transport of oxygen in the blood.
B. Neutrophils are another type of white blood cell that is essential for fighting bacterial infections. They are part of the body's immune response but do not transport oxygen.
C. Platelets are small cell fragments that are crucial for blood clotting and wound repair. They do not have a role in oxygen transport.
D. Hemoglobin is the primary molecule responsible for transporting oxygen in the blood. It is a protein found in red blood cells (erythrocytes) that binds to oxygen in the lungs and releases it in tissues throughout the body. Hemoglobin carries the majority of oxygen in the bloodstream and is essential for effective oxygen transport and delivery.
Correct Answer is B
Explanation
A. Using the same IV catheter for a second insertion attempt is not advisable. Once an IV catheter has been inserted, it should not be reused or reinserted in the same or a different site. If the initial insertion fails or if the catheter needs to be repositioned, a new sterile catheter should be used.
B. If there is any suspicion of contamination during the insertion of an IV catheter, it is important to replace the catheter to prevent infection. This is crucial for maintaining sterility and reducing the risk of introducing pathogens into the patient’s bloodstream.
C. The IV catheter should be removed once the course of IV antibiotics or any other IV therapy is completed, unless there is a specific medical reason to keep it in place. Leaving the catheter in place unnecessarily increases the risk of infection and other complications.
D. Disconnecting the IV infusion for a client to use the restroom is not typically recommended as a standard practice. Disconnecting can introduce risks of infection and requires thorough cleaning and handling. Instead, a safer practice is to secure the IV line and allow the client to use the restroom while keeping the infusion running, or use a specialized catheter with a secure, closed system.
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