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 C
Explanation
Choice A reason: This is an incorrect choice because "When did you first seek health care for your symptoms?" is not an example of back-channeling. Back-channeling is a communication technique that involves using verbal or non-verbal cues to indicate that the listener is paying attention and encouraging the speaker to continue. This statement is an example of an open-ended question, which is another communication technique that involves asking questions that require more than a yes or no answer and elicit more information from the speaker.
Choice B reason: This is an incorrect choice because "I am sure the doctor will answer all of your questions shortly." is not an example of back-channeling. Back-channeling is a communication technique that involves using verbal or non-verbal cues to indicate that the listener is paying attention and encouraging the speaker to continue. This statement is an example of a reassurance, which is another communication technique that involves expressing confidence or support to the speaker and alleviating their anxiety or fear.
Choice C reason: This is the correct choice because "I completely understand. Can you tell me more?" is an example of back-channeling. Back-channeling is a communication technique that involves using verbal or non-verbal cues to indicate that the listener is paying attention and encouraging the speaker to continue. This statement is an example of a verbal cue, which involves using words or phrases that show empathy, interest, or agreement, and invite the speaker to elaborate or clarify their message.
Choice D reason: This is an incorrect choice because "Try not to worry. I'm sure that you will be just fine." is not an example of back-channeling. Back-channeling is a communication technique that involves using verbal or non-verbal cues to indicate that the listener is paying attention and encouraging the speaker to continue. This statement is an example of a false reassurance, which is a communication barrier that involves making unrealistic or unfounded promises or predictions to the speaker and dismissing their concerns or feelings.
Correct Answer is D
Explanation
Choice A reason: This is an incorrect choice because soaking the crusted areas of tape with adhesive remover is not the best approach to change nasogastric tube tape that has become crusted with secretions. Adhesive remover is a solvent that can dissolve the glue that holds the tape to the skin. However, it can also irritate the skin and cause redness, burning, or allergic reactions. The nurse should avoid using adhesive remover on the patient's face, especially near the eyes, nose, or mouth.
Choice B reason: This is an incorrect choice because saturating the tape with a denatured alcohol solution is not the best approach to change nasogastric tube tape that has become crusted with secretions. Denatured alcohol is a mixture of ethanol and other chemicals that can dissolve the glue that holds the tape to the skin. However, it can also dry out the skin and cause cracking, peeling, or bleeding. The nurse should avoid using denatured alcohol on the patient's face, especially near the eyes, nose, or mouth.
Choice C reason: This is an incorrect choice because using blunt-edged scissors to loosen the tape from the skin is not the best approach to change nasogastric tube tape that has become crusted with secretions. Blunt-edged scissors are scissors that have rounded tips instead of sharp points. They can be used to cut the tape without injuring the skin. However, they can also pull or tug on the skin and cause pain, discomfort, or damage. The nurse should avoid using scissors on the patient's face, especially near the eyes, nose, or mouth.
Choice D reason: This is the correct choice because softening the secretions using a warm moist washcloth is the best approach to change nasogastric tube tape that has become crusted with secretions. A warm moist washcloth is a cloth that is soaked in warm water and wrung out. It can be applied gently to the crusted areas of tape to soften the secretions and loosen the tape from the skin. It can also soothe the skin and prevent irritation or infection. The nurse should use a clean washcloth for each application and discard it after use.
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