The registered nurse is performing the steps of a time-out. Which components should
be included? Select all that apply.
.
Y Patient stating his/her full name
Rationale: This is the most commonly used patient identifier.
Y Patient stating his/her date of birth
Rationale: This is often used as the second identifier.
Y Patient stating the site of the procedure
Rationale: This is asked during time-out to validate the correct surgery is being
performed.
Y Patient stating his/her social security number
Rationale: Less commonly used, but this is an acceptable identifier
N Patient stating his/her allergies
Rationale: Allergies are not a part of the time-out process.
Test Taking Tips:Focus on the points of time-out.
Which is true regarding informed consent?
Y It includes the reason for the surgery.
It includes type of instruments used for surgery.
Rationale: Type of instruments used may not be included in the informed consent.
It includes the reason for the surgery.
Rationale: Informed consent includes name, type, and reason for the surgery.
It includes the name of the registered nurse.
Rationale: Informed consent includes the name of the surgeon but not the registered
nurse.
It includes the allergic history of the patient.
Rationale: Informed consent may not include the allergic history of the patient.
Test Taking Tips:Informed consent is an educated patient.
The surgeon, after talking to the mother of a 1-year-old infant scheduled for heart
surgery, decides to postpone surgery. Which statement made by the infant's mother
most likely influenced the surgeon's decision?
Y "I fed the infant formula 2 hours ago."
Rationale: Infant formula can be given up to 6 hours before surgery. Therefore, the
surgery may be postponed to prevent the risk of aspiration if an infant has been fed only
2 hours prior.
N "I fed the infant an apple 8 hours ago."
Rationale: Solid foods such as apples may be given 8 hours before surgery.
N "I fed the infant grape juice 6 hours ago."
Rationale: Grape juice is a clear liquid without pulp that can be given 2 hours before
surgery.
N "I fed the infant breast milk 4 hours ago."
Rationale: Breast milk may be given 4 hours before surgery.
Test Taking Tips:Safety is the priority.
, The nurse has concerns that there may be a risk for deep vein thrombosis in a patient
who is scheduled for hip replacement. Which statement made by the patient most likely
supports the nurse's suspicion?
N "I drink two glasses of wine per week."
Rationale: Intake of alcohol may decrease the response to anesthesia.
N "I have been diagnosed with asthma recently."
Rationale: Asthma may not be a risk factor for deep vein thrombosis.
N "I am allergic to few anesthetic agents."
Rationale: Allergy to few anesthetic agents may cause allergic reactions such as
rashes, which may cause further complications and lead to anaphylaxis.
Y "I smoke five packs of cigarettes per day."
Rationale: Smoking may increase the risk of deep vein thrombosis postoperatively and
cause respiratory depression intraoperatively.
Test Taking Tips:Consider risk factors.
Which postoperative complications is the nurse most likely to anticipate in a patient with
preoperative anxiety who is scheduled for surgery? Select all that apply.
Y Deep vein thrombosis
Rationale: Anxiety may affect the recovery by decreasing the activity and mobility, which
increases the risk of deep vein thrombosis.
Delayed wound healing
Rationale: Smoking may increase the healing time and thus causes delayed wound
healing.
Decreased risk of infection
Rationale: Anxiety increases the risk for infection by decreasing the immune system
response.
Y Increased postoperative pain
Rationale: Anxiety increases the postoperative pain and thus necessitates the
requirement of more pain medications.
Decreased response to anesthesia
Rationale: Alcohol and drugs may compromise the patient's response to anesthesia.
Test Taking Tips:Anxiety may increase the risk of most of the postoperative
complications.
Which postoperative complications is the nurse most likely to anticipate in a patient with
a history of chronic smoking who is scheduled for a surgery?
Delayed wound healing
Limited postoperative pain
Decrease in the response to anesthesia
Decreased immune system response
Test Taking Tips:"Chronic smoking" are the key words.
Y Delayed wound healing
Rationale: Smoking may increase the healing time and thus causes delayed wound
healing.