° Test-Taking Strategy: Focus on the subject, safeguarding the client’s necklace. Focusing on the subject and noting the word “lock” in the correct option will help you answer correctly. Review: the procedures for safeguarding a client’s valuables . ° Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 1387). St. Louis: Mosby. ° Cognitive Ability: Applying ° Client Needs: Safe and Effective Care Environment ° Integrated Process: Nursing Process/Implementation ° Content Area: Ethical/Legal ° Giddens Concepts: Ethics, Health Care Policy ° HESI Concepts: Advocacy/Ethical/Legal Issues, Health Policy/Systems—Health Care Policy Awarded 1.0 points out of 1.0 possible points. ° 9. ID: 8482550827 The nurse providing preoperative care to a client who is scheduled for a left mastectomy and axillary lymph node dissection notes that the client is wearing a wedding band on her left ring finger. Which action should the nurse take?
Tape the wedding band in place Explain to the client why the wedding band must be removed Correct Ask the client whether she would like to remove the wedding band or wear it to surgery Ask the client to sign a release to free the hospital of responsibility if the wedding band is lost during surgery ° Rationale: In most situations a wedding band may be taped in place and worn during a surgical procedure. However, if the possibility exists that the client will experience swelling of the hand or fingers, the wedding band should be removed. On admission to a healthcare facility, the client is asked to sign a form that frees the agency from responsibility if a client’s valuable is lost. After mastectomy with axillary lymph node dissection, the client is at risk for lymphedema, which results in swelling of the arm and hand on the affected side. Therefore the appropriate nursing action is to ask the client to remove the wedding band and explain why. ° Test-Taking Strategy: Focus on the data in the question. Eliminate the options that are comparable or alike in that they indicate that the client may wear the wedding band during the surgical procedure. Next, recall the complications associated with mastectomy, which will direct you to the correct option. Review: preoperative procedures for a client’s valuables . ° Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 1387). St. Louis: Mosby. ° Cognitive Ability: Applying ° Client Needs: Safe and Effective Care Environment ° Integrated Process: Nursing Process/Implementation ° Content Area: Perioperative Care ° Giddens Concepts: Cellular Regulation, Fluid and Electrolyte Balance ° HESI Concepts: Cellular Regulation, Fluids and Electrolytes Awarded 1.0 points out of 1.0 possible points.
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