Exhibits Here
The nurse is preparing the client for surgery. Which of the following actions should the nurse take? Select all that apply.
A.
Obtain a complete blood count.
B.
Prepare the client for insertion of an 18-gauge peripheral IV prior to surgery.
C.
Administer Rh, D immune globulin prior to surgery.
D.
Explain the surgical procedure to the client.
E.
Verify consent form is signed by the client.
F.
Assist with the administration of AB-positive blood products if needed.
G.
Remind the client to be NPO prior to surgery.
The Correct Answer and Explanation is:
The correct answers are B, E, and G.
Explanation
When preparing a client for surgery, nurses must follow specific protocols to ensure patient safety and optimal outcomes. Here’s a detailed breakdown of the correct actions:
B. Prepare the client for insertion of an 18-gauge peripheral IV prior to surgery.
An 18-gauge IV is typically used in surgical settings because it allows for the rapid infusion of fluids and medications. This size is particularly important for surgeries that may involve significant fluid loss or require quick access to administer medications, such as anesthesia or blood products. Establishing this IV access before the surgery is a critical step to facilitate smooth perioperative management.
E. Verify consent form is signed by the client.
Ensuring that the consent form is signed and in the client’s chart is a legal and ethical requirement before any surgical procedure. The nurse should confirm that the client understands the procedure, its risks, benefits, and alternatives, and has voluntarily agreed to proceed. Failure to obtain proper consent can lead to legal ramifications and compromise the client’s autonomy and rights.
G. Remind the client to be NPO prior to surgery.
NPO (nil per os, or nothing by mouth) guidelines are crucial before surgery to prevent aspiration during anesthesia. The client should be advised to abstain from food and drink for a specified period (usually 6-8 hours before surgery), as per facility protocol. This precaution helps ensure the stomach is empty, reducing the risk of complications.
Why the others are not selected:
- A. Obtain a complete blood count. While obtaining a complete blood count may be a routine part of preoperative assessment, it is not an immediate action the nurse must take right before surgery unless specific indications suggest otherwise.
- C. Administer Rh, D immune globulin prior to surgery. This is specific to certain scenarios (e.g., Rh-negative mothers), and not a general requirement for all surgical clients.
- F. Assist with the administration of AB-positive blood products if needed. This action is not usually performed by the nurse unless it’s specified that the client needs a transfusion preoperatively. Blood transfusions are typically managed in the context of the intraoperative or postoperative setting.
By focusing on these essential actions, the nurse ensures that the client is properly prepared and that safety protocols are upheld.