While preparing the surgical instruments for sterilization, the nurse notices visible residue on some of the instruments. What action should the nurse take?

Correct Answer: A

Rationale: If visible residue is noticed on the surgical instruments, it is crucial to re-sterilize them before using them for any procedure. Visible residue may indicate that the instruments are not sterile and could potentially introduce contaminants into the patient during the procedure, leading to infection or other complications. It is essential to maintain the highest standards of cleanliness and sterility in healthcare settings to ensure patient safety. Therefore, the nurse should take immediate action to re-sterilize the instruments before proceeding with any surgical procedure.

Correct Answer: C

Rationale: It is crucial to have a complete set of surgical instruments for any surgical procedure to ensure patient safety and the success of the surgery. If the nurse notices that the surgical instrument tray is incomplete, the best course of action is to inform the sterile processing department immediately. By doing so, the missing instruments can be promptly provided, ensuring that the surgical team has all the necessary tools for the procedure. Proceeding with the procedure using incomplete instruments can compromise patient safety and the quality of care provided. Documenting the missing instruments in the surgical count log is important for record-keeping purposes but should not delay the immediate action of requesting additional instruments. Borrowing instruments from another OR is not recommended as it can create confusion, potential cross-contamination, and disrupt the workflow of another surgical team.

Correct Answer: C

Rationale: Reflecting the patient's feelings and expressions is a therapeutic communication technique that involves mirroring back the patient's emotions and thoughts. By doing this, the nurse validates the patient's experiences and helps them explore their feelings further. This technique can enhance the patient's self-awareness and promote emotional expression, leading to a deeper understanding of their conflicting emotions. Offering advice (Option A) may not be as effective because the focus should be on helping the patient process their own emotions. Providing reassurance and false hope (Option B) can hinder the patient's emotional exploration and may lead to trust issues if the reality does not align with the false reassurance. Redirecting the conversation to a different topic (Option D) avoids addressing the patient's conflicting emotions, which is crucial for therapeutic communication and support.

Correct Answer: B

Rationale: The nurse should provide accurate information about the medication, including potential side effects, to address the patient's concerns. It is important for the nurse to listen to the patient's worries and provide them with the knowledge they need to make an informed decision about their treatment. By educating the patient about the medication and its potential side effects, the nurse empowers the patient to be actively involved in their care and promotes shared decision-making. Disregarding the patient's concerns, encouraging them to stop taking the medication, or minimizing the importance of their worries are not appropriate responses and may negatively impact the patient-nurse relationship and the patient's adherence to the prescribed treatment.

Correct Answer: C

Rationale: The nurse should prioritize checking the patency of the NG tube by aspirating gastric contents before initiating tube feeding. This is important to ensure that the NG tube is in the correct position and that it is functioning properly. By aspirating gastric contents, the nurse can confirm that the tube is in the stomach and not in the lungs or surrounding tissues. If no gastric contents are obtained upon aspiration, it may indicate that the tube is not properly placed or may be occluded, which would require further assessment and intervention before proceeding with tube feeding. Checking the patency of the NG tube is a crucial step in ensuring the safety and effectiveness of enteral nutrition delivery.