The nurse is caring for a patient who will be having surgery shortly. The patient requests that a religious bracelet be worn in the operating room to help ensure a good surgical outcome. Which is the most appropriate action of the nurse?
Insist that the patient remove the bracelet and give it to a family member during surgery.
Notify the patient’s surgeon of the patient’s refusal to remove the bracelet before having surgery.
Call the operating room staff to determine if the bracelet can stay on during surgery.
Remove the bracelet from the patient's wrist after sedating medication has been administered.
The Correct Answer is C
Choice A reason: This is an incorrect choice because insisting that the patient remove the bracelet and give it to a family member during surgery is not the most appropriate action of the nurse. This action may violate the patient's right to autonomy, religious freedom, and cultural sensitivity. The nurse should respect the patient's beliefs and preferences and try to accommodate them as much as possible, unless they pose a significant risk to the patient's safety or the surgical procedure.
Choice B reason: This is an incorrect choice because notifying the patient’s surgeon of the patient’s refusal to remove the bracelet before having surgery is not the most appropriate action of the nurse. This action may imply that the patient is non-compliant or difficult, and may create a conflict between the patient and the surgeon. The nurse should communicate with the patient and the surgeon in a respectful and collaborative manner, and seek a mutually agreeable solution.
Choice C reason: This is the correct choice because calling the operating room staff to determine if the bracelet can stay on during surgery is the most appropriate action of the nurse. This action shows that the nurse is willing to advocate for the patient and to consult with the relevant authorities to find out the best option. The nurse should follow the policies and protocols of the operating room and the infection control guidelines, and ensure that the bracelet does not interfere with the surgical site, the equipment, or the sterile field.
Choice D reason: This is an incorrect choice because removing the bracelet from the patient's wrist after sedating medication has been administered is not the most appropriate action of the nurse. This action may be considered unethical, dishonest, or disrespectful, as the nurse is taking advantage of the patient's altered mental status and going against the patient's wishes. The nurse should obtain the patient's informed consent before performing any intervention, and should not deceive or coerce the patient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is an incorrect choice because "Are you having any difficulty breathing right now?" is not an open-ended question. An open-ended question is a question that requires more than a yes or no answer and elicits more information from the speaker. This question can be answered with a yes or no, and does not encourage the patient to describe their condition in detail.
Choice B reason: This is the correct choice because "What does your chest pain feel like?" is an open-ended question. An open-ended question is a question that requires more than a yes or no answer and elicits more information from the speaker. This question invites the patient to describe the quality, intensity, location, and duration of their chest pain, which can help the nurse to assess the possible cause and severity of the problem.
Choice C reason: This is an incorrect choice because "Do you have a family history of heart disease?" is not an open-ended question. An open-ended question is a question that requires more than a yes or no answer and elicits more information from the speaker. This question can be answered with a yes or no, and does not encourage the patient to provide more details about their health history or risk factors.
Choice D reason: This is an incorrect choice because "How long have you been experiencing chest pain?" is not an open-ended question. An open-ended question is a question that requires more than a yes or no answer and elicits more information from the speaker. This question can be answered with a specific time, and does not encourage the patient to provide more information about their symptoms or situation.
Correct Answer is A
Explanation
Choice A reason: This is the correct choice because providing a warm cup of hot chocolate may make it more difficult for the patient to fall asleep. Hot chocolate contains caffeine and sugar, which are stimulants that can interfere with the sleep cycle and cause insomnia. The nurse should avoid giving the patient any beverages or foods that contain caffeine or sugar before bedtime.
Choice B reason: This is an incorrect choice because giving the patient a gentle backrub may make it easier for the patient to fall asleep. A backrub is a relaxation technique that can reduce muscle tension, pain, and anxiety, and promote comfort and sleep. The nurse should offer the patient a backrub or other soothing interventions before bedtime.
Choice C reason: This is an incorrect choice because encouraging the patient to use the bathroom may make it easier for the patient to fall asleep. Using the bathroom before bed can prevent nocturia, which is the need to urinate at night, and allow the patient to have uninterrupted sleep. The nurse should assist the patient to use the bathroom or provide a urinal or bedpan if needed.
Choice D reason: This is an incorrect choice because giving the patient an extra blanket when cold may make it easier for the patient to fall asleep. Maintaining a comfortable temperature is important for sleep quality and quantity. The nurse should adjust the room temperature and provide extra blankets or fans as requested by the patient.
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