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 incorrect. Hydromorphone 0.5 mg IV is not the best option for providing consistent control of the patient's chronic pain. Hydromorphone is a potent opioid analgesic that can relieve severe pain, but it has a short duration of action. It is given intravenously, which means it has a rapid onset and peak, but also a rapid decline and elimination. The patient may experience fluctuations in pain relief and need frequent doses.
Choice B reason: This is correct. Fentanyl transdermal patch 25 mcg is the best option for providing consistent control of the patient's chronic pain. Fentanyl is a potent opioid analgesic that can relieve severe pain, but it has a long duration of action. It is given transdermally, which means it is absorbed through the skin and released slowly and steadily into the bloodstream. The patient may experience continuous and stable pain relief and need less frequent doses.
Choice C reason: This is incorrect. Fentanyl oral lozenge 200 mcg is not the best option for providing consistent control of the patient's chronic pain. Fentanyl is a potent opioid analgesic that can relieve severe pain, but it has a short duration of action. It is given orally, which means it has to pass through the digestive system and the liver before reaching the bloodstream. The patient may experience delayed and variable pain relief and need frequent doses.
Choice D reason: This is incorrect. Morphine sulfate liquid 10 mg is not the best option for providing consistent control of the patient's chronic pain. Morphine is a moderate opioid analgesic that can relieve moderate to severe pain, but it has a short duration of action. It is given orally, which means it has to pass through the digestive system and the liver before reaching the bloodstream. The patient may experience delayed and variable pain relief and need frequent doses.
Correct Answer is B
Explanation
Choice A reason: This is an incorrect choice because temperature, pulse, and blood pressure are not the most important vital signs for a patient who is experiencing shortness of breath. Temperature is not directly related to respiratory function, and pulse and blood pressure can be affected by other factors, such as anxiety or medication.
Choice B reason: This is the correct choice because pulse, respirations, and oxygen saturation are the most important vital signs for a patient who is experiencing shortness of breath. Pulse reflects the heart rate and rhythm, which can be altered by respiratory distress. Respirations reflect the rate and depth of breathing, which can indicate the severity of the condition. Oxygen saturation reflects the percentage of hemoglobin that is bound with oxygen, which can indicate the adequacy of oxygenation.
Choice C reason: This is an incorrect choice because temperature, pulse, and respirations are not the most important vital signs for a patient who is experiencing shortness of breath. Temperature is not directly related to respiratory function, and respirations alone do not provide enough information about the oxygenation status of the patient.
Choice D reason: This is an incorrect choice because respirations, blood pressure, and pain are not the most important vital signs for a patient who is experiencing shortness of breath. Blood pressure can be affected by other factors, such as anxiety or medication, and pain is a subjective symptom that can vary from person to person. Oxygen saturation is a more objective and reliable indicator of oxygenation than pain.
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