In the operating room, an 82-year-old client tells the circulating nurse that cataract surgery is to be performed on the left eye. The nurse notes that the consent form indicates the right eye. What is the nurse’s best action?
Notify the surgeon and anesthesiologist.
Assume that the client is confused because he is elderly.
Ask the client to point to his good eye.
Check to see if the client has received any preoperative medications.
The Correct Answer is A
Choice A reason: Notifying the surgeon and anesthesiologist is the most appropriate action. This ensures that the discrepancy is addressed immediately and the correct eye is operated on. It is crucial to verify and correct any inconsistencies in the surgical plan to prevent errors and ensure patient safety.
Choice B reason: Assuming that the client is confused because he is elderly is inappropriate and dismissive. Age should not be a factor in disregarding a patient’s statement. The nurse should take the client’s concerns seriously and verify the information rather than making assumptions about the client’s mental state.
Choice C reason: Asking the client to point to his good eye can help clarify the situation, but it is not sufficient on its own. While it may provide additional information, the nurse must still notify the surgical team to ensure that the correct procedure is performed. This step should be part of the verification process but not the sole action taken.
Choice D reason: Checking to see if the client has received any preoperative medications is important, but it does not address the immediate concern of the discrepancy in the consent form. The priority is to ensure that the correct eye is identified for surgery, and this requires notifying the surgical team.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Fine crackles are often associated with bronchitis, particularly chronic bronchitis. These sounds are caused by the presence of mucus in the airways, which creates a crackling noise when air passes through. Chronic bronchitis involves inflammation and increased mucus production in the bronchi, leading to these characteristic lung sounds.
Choice B reason: A pneumothorax, or collapsed lung, typically presents with absent or diminished breath sounds on the affected side rather than fine crackles. The absence of breath sounds is due to the lack of air movement in the collapsed portion of the lung. Fine crackles are not a common finding in pneumothorax.
Choice C reason: Asthma is characterized by wheezing, which is a high-pitched whistling sound caused by narrowed airways. While crackles can occasionally be heard in asthma, they are not the primary lung sound associated with this condition. Wheezing is more indicative of asthma due to bronchoconstriction and inflammation.
Choice D reason: Emphysema, a form of chronic obstructive pulmonary disease (COPD), typically presents with decreased breath sounds and prolonged expiration rather than fine crackles. The destruction of alveolar walls in emphysema leads to reduced lung sounds overall. Fine crackles are not a hallmark of emphysema.
Correct Answer is D
Explanation
Choice A Reason:
Notifying the surgeon of the blood pressure is important, but it is not the first action the nurse should take. The primary concern is to manage the patient’s high blood pressure to prevent any complications during surgery. Once the blood pressure is under control, the nurse can then notify the surgeon if necessary.
Choice B Reason:
Documenting the blood pressure on the pre-op checklist is a necessary step, but it is not the immediate priority. The nurse’s first action should be to address the elevated blood pressure to ensure the patient’s safety. Documentation can be done after the immediate concern is managed.
Choice C Reason:
Having the client relax and take deep breaths can help lower blood pressure temporarily, but it is not a sufficient intervention for a blood pressure reading as high as 174/88. The nurse should take a more direct approach to manage the hypertension, such as administering the prescribed antihypertensive medication.
Choice D Reason:
Administering the antihypertensive medication is the most appropriate first action. The patient is NPO (nothing by mouth) except for medications, indicating that the medication should still be given. This action directly addresses the elevated blood pressure and helps to stabilize the patient before surgery.
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