during an emergency procedure is the surgical timeout a requirement

NCLEX-PN

Nclex PN Questions and Answers

1. During an emergency procedure, is the surgical timeout a requirement?

A. The surgical timeout should be performed by the surgical team unless it would cause a delay leading to injury or death.
B. No, the timeout is not necessary during an emergency procedure.
C. No, the surgical timeout is not required in emergency procedures.
D. Yes, the surgical timeout must be performed in all cases.

Correct answer: A

Rationale: During an emergency procedure, the surgical timeout should be performed unless doing so would cause a delay leading to injury or death. This is because the primary goal during an emergency is to swiftly address the critical situation. Choice B is incorrect as it implies that the timeout is not necessary, which is not accurate. Choice C is also incorrect as it suggests that the timeout is not required in emergency procedures, disregarding safety protocols. Choice D is incorrect as it wrongly states that the timeout must be performed in all cases without considering the potential risks associated with delays during emergencies.

2. Which action by the nurse represents the ethical principle of benevolence?

A. The nurse administers an immunization to a child even though it may cause discomfort
B. The nurse follows a plan of care designed to relieve pain in a client with cancer
C. The nurse provides equal amounts of care to all assigned clients on the basis of illness acuity
D. The nurse upholds a client's decision to refuse chemotherapy for lung cancer

Correct answer: A

Rationale: Benevolence is taking action to help others. In this scenario, administering an immunization to a child, even though it may cause discomfort, aligns with the principle of benevolence as the benefits of protection from disease outweigh the temporary discomfort. Fidelity refers to keeping promises made to clients, families, and other healthcare professionals. Autonomy is a person's independence, and respecting autonomy means agreeing to respect an individual's right to determine their course of action. Justice refers to fairness and equity, including the fair allocation of resources, such as nursing care for all clients. Choice B is incorrect as it pertains more to the ethical principle of beneficence rather than benevolence, which focuses on doing good for others without an expectation of something in return. Choices C and D are incorrect as they do not directly align with the principle of benevolence.

3. A nurse is taking a morning break with the unit secretary in the nurses' lounge. The unit secretary says to the nurse, 'I read in Mr. Gage's medical record that he has gonorrhea.' How should the nurse respond to the secretary?

A. Yes, he does, but be sure not to discuss this with anyone else.
B. Yes, that's why we've imposed contact precautions.
C. We can't discuss a client's medical condition.
D. Oh, really? I didn't see that!

Correct answer: C

Rationale: A client's medical condition is confidential and should never be discussed with anyone other than the client and the client's healthcare provider. Therefore, the nurse must tell the unit secretary that the client's condition is not to be discussed. Choices A and B confirm the client's disease, which is inappropriate as it breaches patient confidentiality. Choice D promotes further discussion of the client's condition, which is also inappropriate. The correct response is to firmly state, 'We can't discuss a client's medical condition,' to uphold patient privacy and confidentiality.

4. What is distraction therapy?

A. Focusing one's attention on stimuli other than pain.
B. Cognitive reappraisal.
C. The replacement of positive images of pain with other images.
D. The use of medication and meditation.

Correct answer: A

Rationale: Distraction therapy involves directing attention away from pain towards positive stimuli, which can help reduce the perception of pain. Choice A is the correct answer as it accurately defines distraction therapy. Cognitive reappraisal (Choice B) involves changing the way one thinks about a situation to alter its emotional impact, which is different from distraction therapy. Choice C is incorrect because distraction therapy does not involve replacing images of pain with other images, but rather focusing on something unrelated. Choice D is incorrect as distraction therapy does not necessarily involve medication or meditation, but rather the redirection of attention.

5. The nurse is preparing task assignments for the day. Which task should the nurse assign to a nursing assistant?

A. Monitoring for bleeding for a client who has just undergone cardiac catheterization
B. Assisting a client who is getting up to ambulate for the first time after surgery
C. Providing oral care to an unconscious client who requires oral care
D. Completing the preoperative checklist for a client scheduled for a liver biopsy

Correct answer: C

Rationale: When delegating tasks, the nurse must consider the state nursing practice act guidelines and job descriptions. Providing oral care to an unconscious client is a task suitable for delegation to a nursing assistant. The nurse should give clear instructions on adapting the procedure for the client's needs and the signs of complications to watch for. Monitoring for bleeding after cardiac catheterization necessitates immediate nursing assessment, which requires critical thinking and intervention that exceeds a nursing assistant's scope of practice. Assisting a client with ambulation post-surgery carries the risk of orthostatic hypotension and should be performed by a licensed nurse. Completing a preoperative checklist for a client scheduled for a liver biopsy involves critical assessment and preparation that are within the nurse's scope of practice.