Practice Question
A nurse is caring for a client who is scheduled for a procedure. Which of the following actions should the nurse take during the time-out? (Select All that Apply)
Answer Choices:
Correct Answer:
Ask the client to state the surgery being performed
Rationale:
💎 1️⃣ Ask the client to state the surgery being performed
🟢During the time-out procedure, the nurse must actively involve the client by asking them to verbalize the procedure they are expecting to undergo.
🟢This step ensures that the client’s understanding matches the surgical consent and prevents wrong-procedure or wrong-site surgery.
🟢Active confirmation by the patient adds an extra layer of safety verification beyond chart reviews.
🟢If the client’s response differs from the scheduled procedure, the nurse must pause the process and clarify with the surgical team before proceeding.
🟢Including the patient in verification reinforces patient-centered care and accountability.
🔷 2️⃣ Verify that the surgical site has been marked
🟢Surgical site marking is a critical safety step for procedures involving right/left or multiple-site operations (e.g., limbs, kidneys, eyes).
🟢The nurse should verify that the surgeon marked the site with an indelible marker before sedation and that it matches the operative consent form.
🟢This confirmation prevents wrong-site surgery, a sentinel event with serious consequences.
🟢The mark should be visible after skin prep and draping. If unclear or missing, the nurse must stop the procedure until verified.
🟢Proper marking aligns with Joint Commission’s Universal Protocol to ensure surgical accuracy and safety.
🟢 3️⃣ Ask the client to read their identification bracelet
🟢Having the client read their own ID bracelet aloud helps confirm correct identification and ensures the right patient is about to undergo surgery.
🟢The nurse compares this information to the surgical consent form, health record, and schedule.
🟢This step also helps detect clerical errors or mix-ups, especially in facilities with multiple patients having similar names.
🟢If the client is unable to speak (e.g., sedated or nonverbal), verification must be done using two identifiers and confirmed by the care team.
🟢Proper identification is a legal and ethical priority before any invasive procedure.
🔶 4️⃣ Use two acceptable client identifiers
🟢The nurse must always confirm patient identity using two unique identifiers, such as name and date of birth, or medical record number—never a room or bed number.
🟢This ensures the correct patient receives the correct treatment and eliminates potential human error.
🟢The identifiers are compared to the surgical consent form, medical record, and provider order during the time-out.
🟢This process follows national patient safety goals established by the Joint Commission to reduce preventable errors.
🟢Proper identification is especially vital before procedures involving anesthesia, transfusions, or invasive interventions.
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This question is from Custom NUR 1100 Final Exam Summer 2025 (Dr Santi) which contains 127 questions.
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From Exam
Custom NUR 1100 Final Exam Summer 2025 (Dr Santi)
127 Questions
View Full Exam Start PracticingQuestion Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Fundamentals of Nursing
- Answer Choices: 5