The nurse is preparing a client for surgery in ine pre-operative setting. Which of the following is not the responsibility of the RN?

Explaining the purpose, risks, benefit, and alternatives of the surgery

Witnessing the client’s signature on the consent form

Conducting a baseline physical assessment and obtaining vital signs

Ensuring the pre-operative checklist is completed

Answer and Explanation

The Correct Answer is A

A) Explaining the purpose, risks, benefit, and alternatives of the surgery: This is not the responsibility of the RN. The role of explaining the purpose, risks, benefits, and alternatives of the surgery falls under the responsibility of the surgeon or the healthcare provider performing the procedure. The RN can provide general information and support but is not responsible for explaining the details of the surgery or obtaining informed consent.

B) Witnessing the client’s signature on the consent form: This is within the RN’s scope of practice. The nurse's role in the consent process is to witness the client's signature, ensuring that it is voluntary and that the client appears to be competent and informed. The nurse does not explain the details of the procedure, but they confirm that the patient has been informed by the surgeon.

C) Conducting a baseline physical assessment and obtaining vital signs: This is an important responsibility of the RN. The nurse conducts a thorough pre-operative assessment, which includes gathering baseline physical data and vital signs. This helps establish a reference point for the client’s health status before surgery and allows for the identification of any abnormalities that may need to be addressed.

D) Ensuring the pre-operative checklist is completed: This is also the RN's responsibility. The nurse ensures that all aspects of the pre-operative checklist, which includes verifying consent, ensuring necessary tests are done, and confirming that the patient is prepared for surgery, are completed. This is part of the nurse’s role in preparing the patient for a safe surgical experience.

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Correct Answer is B

Explanation

A. Hemoglobin and hematocrit count:
Hemoglobin and hematocrit levels are useful in assessing overall blood volume and oxygen-carrying capacity. While these tests can help identify anemia or other hematologic abnormalities that might occur in HIV-infected individuals, they do not provide specific information regarding the stage of HIV infection or the immune function. Therefore, they are not the most helpful for determining the stage of the disease.

B. CD4+ count cell:
The CD4+ count is the most important laboratory test for assessing the progression of HIV. CD4+ T cells are critical components of the immune system, and their count reflects the level of immune suppression in the body. As HIV progresses, the CD4+ count decreases, making the individual more vulnerable to opportunistic infections. A low CD4+ count (typically below 200 cells/mm³) indicates that the individual has progressed to acquired immunodeficiency syndrome (AIDS). Therefore, the CD4+ count provides the most direct insight into the stage of HIV infection.

C. Western blot:
The Western blot test is used to confirm an HIV diagnosis after an initial positive screening test, such as the ELISA. It is not used to assess the stage of the disease. While it helps to confirm the presence of HIV antibodies, it does not provide information about immune function or the progression of the disease.

D. Enzyme-linked immunosorbent assay (ELISA):
The ELISA is a screening test used to detect antibodies against HIV. If the ELISA test is positive, it is usually followed by a confirmatory test (such as the Western blot). While ELISA is important for diagnosing HIV infection, it does not provide information about the current stage or progression of the disease. Therefore, it is not the most helpful test for assessing the stage of HIV infection once the diagnosis is established.

A. Obtaining a primary and secondary tubing set B. Ensuring another licensed personnel is available C. Obtaining 0.9% normal saline solution D. Checking ABO and Rh status of the donor and recipient

Correct Answer is B

Explanation

A) Obtaining a primary and secondary tubing set:
The primary tubing is used for the intravenous access, and the secondary tubing is attached for administering the blood product. This ensures that the blood transfusion will be delivered effectively, and it is a standard practice to use proper IV tubing for blood products to avoid contamination or complications.

B) Ensuring another licensed personnel is available:
. While it is required that two licensed healthcare professionals verify the blood product before starting the transfusion, this action itself is not contraindicated, it is required. Both individuals should independently check the patient's identification, blood type, and the matching of the blood product before administration. Therefore, the answer to the question should not be about ensuring availability of licensed personnel as this is actually a required safety measure, not contraindicated. The actual contraindications involve actions like using inappropriate fluids for transfusion or mismatching blood.

C) Obtaining 0.9% normal saline solution:
This is appropriate and necessary when preparing for a blood transfusion. Normal saline (0.9%) is the only compatible solution that should be used to flush the IV line before and after the transfusion or to prime the blood tubing. Other solutions, such as lactated Ringer's, can cause clotting when mixed with blood, making saline the only appropriate choice.

D) Checking ABO and Rh status of the donor and recipient:
This is essential and mandatory before administering a blood transfusion. It is critical to ensure that the ABO blood group and Rh factor of the donor and recipient are compatible to prevent hemolytic reactions. This compatibility check must be done every time before administering a transfusion, and it is an integral part of ensuring patient safety.

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The nurse is preparing a client for surgery in ine pre-operative setting. Which of the following is not the responsibility of the RN?

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