During surgery, the nurse notices a discrepancy between the surgical count and the number of instruments on the sterile field. What should the nurse do?

Correct Answer: D

Rationale: If a nurse notices a discrepancy between the surgical count and the number of instruments on the sterile field during surgery, it is crucial to inform the surgical team immediately and initiate a thorough search. Patient safety is of utmost importance, and any missing instruments could potentially pose a risk to the patient. By informing the team and conducting a thorough search, the missing instrument can be located promptly to ensure it is not inadvertently left inside the patient's body. Continuing with the procedure or ignoring the discrepancy without further investigation could lead to serious consequences for the patient's well-being. It is always better to address any discrepancies or concerns during surgery proactively to maintain a high standard of patient care and safety.

Correct Answer: C

Rationale: When a nurse discovers a discrepancy between the medication order and the patient's medication record, the priority action is to verify the medication order with the prescriber to ensure accuracy and patient safety. Administering the medication without clarification can put the patient at risk. Documenting the discrepancy and informing the charge nurse is important, but it should not delay verifying the order with the prescriber. Contacting the pharmacy for clarification may be necessary in some cases, but the immediate action should be to confirm the prescription with the prescriber to prevent errors and ensure the patient receives the correct medication.

Correct Answer: A

Rationale: The ethical principle that should guide the nurse's decision-making in this situation is beneficence, which emphasizes the nurse's obligation to act in the best interest of the patient. In this scenario, the nurse must balance the patient's request for pain medication with considerations related to the patient's history of substance abuse. The nurse should prioritize providing effective pain relief for the patient while also considering the potential risks of administering medication to someone with a history of substance abuse. By focusing on beneficence, the nurse can make decisions that promote the well-being and best interests of the patient, taking into account both the immediate need for pain relief and the patient's history of substance abuse.

Correct Answer: C

Rationale: Providing emotional support and addressing psychosocial needs demonstrates palliative care principles when caring for a patient experiencing end-of-life symptoms. Palliative care focuses on holistic care that encompasses physical, emotional, and spiritual support for patients and their families during times of serious illness. By addressing emotional needs and providing support, the nurse helps improve the patient's quality of life and comfort during this difficult time. This approach goes beyond just managing physical symptoms and pain, recognizing the importance of supporting the patient's overall well-being. Encouraging the patient to make decisions about life-sustaining treatments is also an important aspect of palliative care, but providing emotional support and addressing psychosocial needs is crucial in palliative care practice.

Correct Answer: A

Rationale: A nurse should wear sterile gloves and a surgical mask during a lumbar puncture procedure to maintain procedural asepsis. Sterile gloves help prevent contamination of the procedure site and reduce the risk of introducing microorganisms to the puncture site. Surgical masks help minimize the risk of respiratory secretions contaminating the sterile field, which is essential for maintaining asepsis during the procedure. Additionally, proper hand hygiene before and after the procedure is crucial in preventing the spread of infection.