While preparing a client for surgery, the nurse marks the arm that is to be amputated and participates in a “time-out” procedure before the surgery begins.
Which sentinel event is this action intended to prevent?

The lack of healing of the stump.

Ineffective control of the client’s pain.

The removal of the wrong arm.

The client being mildly sedated.

Answer and Explanation

The Correct Answer is C

This action is intended to prevent a sentinel event, which is a patient safety event that results in death, permanent harm, or severe temporary harm. A sentinel event is a serious adverse event that signals the need for immediate investigation and response. Removing the wrong arm would be a devastating and irreversible outcome for the patient and the health care provider.

Choice A is wrong because the lack of healing of the stump is not a sentinel event. It is a possible complication of amputation that may be related to the natural course of the patient’s illness or underlying condition.

Choice B is wrong because ineffective control of the client’s pain is not a sentinel event. It is a quality of care issue that may affect the patient’s comfort and recovery, but it does not result in death, permanent harm, or severe temporary harm.

Choice D is wrong because the client being mildly sedated is not a sentinel event. It is a level of anesthesia that may be appropriate for some types of surgery, but it does not result in death, permanent harm, or severe temporary harm.

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Correct Answer is C

Explanation

his intervention can help prevent pressure ulcers by reducing the amount of pressure on bony prominences and promoting blood circulation to the skin.

Choice A is wrong because placing the patient in a side-lying position only can increase the risk of skin breakdown by limiting the patient’s mobility and exposing the same areas to pressure. The patient should be repositioned frequently and encouraged to change positions if able.

Choice B is wrong because massaging bony prominences can cause tissue damage and increase the risk of skin breakdown by impairing blood flow to the area. Massaging should be avoided over bony prominences and areas of redness.

Choice D is wrong because keeping the head of the bed elevated higher than 30 degrees can cause shearing forces on the skin, which can lead to skin breakdown. The head of the bed should be kept at the lowest degree of elevation possible.

Choice E is wrong because inspecting skin every shift is not enough for a patient at risk for impaired skin integrity. The skin should be inspected at least every 2 hours or more frequently depending on the patient’s condition. Early detection of skin changes can help prevent further damage and promote healing.

Normal ranges for skin integrity are:

• Skin color: consistent with ethnicity and genetic background, no pallor, cyanosis, or jaundice.

• Skin moisture: dry to touch, no excessive perspiration or dryness. • Skin texture: smooth, soft, intact, with even surface.

• Skin temperature: warm to touch, no hyperthermia or hypothermia. • Skin turgor: elastic, returns to original shape after being pinched. • Skin integrity: no lesions, wounds, abrasions, or ulcers.

A. One of the highest levels of evidence are randomized, controlled, double-blind studies. B. Ideas, editorials, and opinions are highly valued in determining EBP. C. The purpose of the hierarchy of evidence is to help the nurse compare patient values with research findings. D. All forms of evidence should be considered equally when.

Correct Answer is A

Explanation

One of the highest levels of evidence are randomized, controlled, double-blind studies. This is because these studies reduce the risk of bias and confounding factors by randomly assigning participants to intervention or control groups, blinding the participants and researchers to the group allocation, and using a placebo or standard treatment as a comparison.

Choice B is wrong because ideas, editorials, and opinions are considered low levels of evidence as they are based on personal views and not on rigorous research methods.

Choice C is wrong because the purpose of the hierarchy of evidence is to help the nurse evaluate the quality and strength of the research findings, not to compare patient values with research findings.

Patient values are important for evidence-based practice, but they are not part of the hierarchy of evidence.

Choice D is wrong because all forms of evidence should not be considered equally when determining evidence-based practice. The hierarchy of evidence ranks different types of research designs according to their validity and applicability, and the nurse should use the highest level of evidence available for their clinical question.

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While preparing a client for surgery, the nurse marks the arm that is to be amputated and participates in a “time-out” procedure before the surgery begins. Which sentinel event is this action intended to prevent?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The RN identifies that a client is at risk for impaired skin integrity. Which interventions should the nurse add to this client’s plan of care?

Correct Answer is C

Explanation

A charge nurse is discussing evidence-based practice (EBP) with a newly licensed nurse. Which of the following information should the nurse include when discussing the hierarchy of evidence?

Correct Answer is A

Explanation

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While preparing a client for surgery, the nurse marks the arm that is to be amputated and participates in a “time-out” procedure before the surgery begins.
Which sentinel event is this action intended to prevent?