A nurse is caring for a client who is scheduled to have surgery. In preparing the client for surgery, which of the following actions is considered outside the nurse’s responsibilities?

Explaining the procedure, risks, and benefits

Reviewing preoperative instructions

Obtaining test results

Ensuring that a signed surgical consent form was completed

Assessing the current health status of the client

Answer and Explanation

The Correct Answer is A

Choice A reason: Explaining the procedure, risks, and benefits

Explaining the surgical procedure, including its risks and benefits, is primarily the responsibility of the surgeon. This is because the surgeon has the detailed knowledge and expertise regarding the specific procedure and can provide comprehensive information to the patient. The nurse’s role in this context is to support the patient by clarifying any information provided by the surgeon and ensuring that the patient understands the instructions. Nurses can also address any immediate concerns or questions the patient might have, but the detailed explanation of the procedure itself is outside their scope of practice.

Choice B reason: Reviewing preoperative instructions

Reviewing preoperative instructions is within the nurse’s responsibilities. Nurses play a crucial role in ensuring that patients understand and follow preoperative instructions, which may include fasting guidelines, medication adjustments, and other preparatory steps. This helps to minimize surgical risks and ensures that the patient is adequately prepared for the procedure. By reviewing these instructions, nurses help to reinforce the information provided by the surgical team and ensure patient compliance.

Choice C reason: Obtaining test results

Obtaining and reviewing test results is also within the nurse’s scope of practice. Nurses are responsible for ensuring that all necessary preoperative tests have been completed and that the results are available for the surgical team. This includes coordinating with the laboratory and other departments to obtain timely results and reviewing them to identify any potential issues that need to be addressed before surgery. This step is critical in ensuring patient safety and readiness for the procedure.

Choice D reason: Ensuring that a signed surgical consent form was completed

Ensuring that a signed surgical consent form is completed is a shared responsibility between the nurse and the surgeon. While the surgeon is responsible for obtaining informed consent by explaining the procedure, risks, and benefits, the nurse’s role is to verify that the consent form has been signed and documented appropriately. This verification process is crucial to ensure that the patient has given informed consent before proceeding with the surgery.

Choice E reason: Assessing the current health status of the client

Assessing the current health status of the client is a fundamental responsibility of the nurse. This involves conducting a thorough health assessment, including taking vital signs, reviewing the patient’s medical history, and identifying any potential risks or concerns that may affect the surgery. This assessment helps to establish a baseline for the patient’s condition and ensures that any necessary precautions are taken to promote a safe surgical outcome.

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Correct Answer is B

Explanation

Choice A reason: Tamoxifen

Tamoxifen is a medication primarily used to treat breast cancer. It works as a selective estrogen receptor modulator (SERM), which means it blocks estrogen receptors in breast tissue. Estrogen can promote the growth of breast cancer cells, so blocking its effects can help to slow or stop the growth of these cells. However, tamoxifen is not typically used for prostate cancer because prostate cancer is driven by androgens (male hormones) rather than estrogens.

Choice B reason: Leuprolide

Leuprolide is a medication commonly used in the treatment of prostate cancer. It is a type of hormone therapy known as a luteinizing hormone-releasing hormone (LHRH) agonist. Leuprolide works by reducing the production of testosterone, a hormone that can stimulate the growth of prostate cancer cells. By lowering testosterone levels, leuprolide helps to slow the progression of prostate cancer and can be used in various stages of the disease.

Choice C reason: Finasteride

Finasteride is a medication used to treat benign prostatic hyperplasia (BPH) and male pattern baldness. It works by inhibiting the enzyme 5-alpha-reductase, which converts testosterone to dihydrotestosterone (DHT). While finasteride can reduce the size of the prostate and improve urinary symptoms in BPH, it is not typically used as a primary treatment for prostate cancer. Its role in prostate cancer is more preventive, as it can lower the risk of developing the disease.

Choice D reason: Cyclophosphamide

Cyclophosphamide is a chemotherapy drug used to treat various types of cancer, including lymphomas, leukemias, and some solid tumors. It works by interfering with the DNA of cancer cells, preventing them from dividing and growing. While cyclophosphamide can be used in certain cancer treatments, it is not a standard treatment for prostate cancer. Prostate cancer is more commonly treated with hormone therapy, targeted therapy, or other specific chemotherapy agents.

A. Check the drainage for glucose. B. Notify the client’s provider. C. Document the amount of drainage. D. Obtain a culture of the drainage.

Correct Answer is A

Explanation

Choice A reason:

Check the drainage for glucose: Clear drainage from the nasal packing after a transsphenoidal hypophysectomy could indicate a cerebrospinal fluid (CSF) leak. CSF leaks are a serious complication that can occur after this type of surgery. Testing the drainage for glucose is a quick and effective way to determine if the fluid is CSF, as CSF contains glucose, whereas normal nasal secretions do not. Identifying a CSF leak promptly is crucial to prevent further complications such as meningitis.

Choice B reason:

Notify the client’s provider: While notifying the provider is important, it should be done after confirming the nature of the drainage. If the drainage is indeed CSF, the provider needs to be informed immediately. However, the initial step should be to check the drainage for glucose to confirm the suspicion.

Choice C reason:

Document the amount of drainage: Documentation is always important in nursing care, but it is not the immediate priority in this situation. The primary concern is to identify the nature of the drainage to address any potential complications promptly.

Choice D reason:

Obtain a culture of the drainage: Obtaining a culture can help identify any infections, but it is not the first step in this scenario. The immediate concern is to determine if the drainage is CSF, which requires checking for glucose.

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A nurse is caring for a client who is scheduled to have surgery. In preparing the client for surgery, which of the following actions is considered outside the nurse’s responsibilities?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has prostate cancer. The nurse should expect the provider to prescribe which of the following medications for this client?

Correct Answer is B

Explanation

A nurse is caring for a client who is 1 day postoperative following a transsphenoidal hypophysectomy. While assessing the client, the nurse notes a large area of clear drainage seeping from the nasal packing. Which of the following should be the nurse’s initial action?

Correct Answer is A

Explanation

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