The nurse is preparing a client for a surgery. Which item is most important to remove before sending the client to surgery?

Appeared in: DHS Staff Nurse - 2018 (Shift-2nd)

Explanation

Under general anesthesia, the protective blink reflex is diminished and tear production decreases.
This causes contact lenses to dry out and stick to the surface of the cornea.
Adherence of the lens to the cornea can lead to painful corneal abrasions, scratches, or ulcers, posing a direct threat to the patient's vision.
This risk of direct physical injury makes removing contact lenses a higher priority than removing items that pose risks of property loss or manageable dangers.

Option A: A hearing aid is removed primarily to prevent its loss or damage during surgery. It does not pose a direct physical threat to the patient.
Option C: A wedding ring poses risks of electrical burns if electrocautery is used or can act as a tourniquet if the finger swells. However, this risk is often manageable.
Option D: An artificial eye is removed to prevent loss, damage, or accidental dislodgement during patient positioning for surgery.

Clinical Relevance

Nursing practice connection: Safe nursing care depends on performing Preoperative patient safety and risk prioritization in the correct sequence, documenting the action clearly, and monitoring for the expected response.
The nurse's role in completing the preoperative checklist is a critical patient safety function. This checklist ensures all potential hazards are addressed before the patient enters the operating room.
Failure to identify and remove contact lenses is a preventable error that can lead to significant patient harm, including pain and potential vision impairment.
What if? If the patient arrives for emergency surgery and is unconscious or unable to communicate, the nurse's priority physical assessment must include checking the eyes for contact lenses and removing them immediately.

How to Approach the Question

Identify the question type: This is a priority question, indicated by the keyword "most important."
Analyze each option by considering the potential harm if the item is NOT removed.
Categorize the type of risk for each option: Is it a risk of direct physical injury, property loss, or a manageable/potential risk?
Apply the nursing principle of prioritizing patient safety. A direct and high probability of physical harm takes precedence over the risk of property loss or a risk that can be mitigated (like taping a ring).
Conclude that the risk of corneal injury from contact lenses is the most severe and immediate threat, making its removal the highest priority.

Concept Tested & Keywords

Q98DKPcIUrNi97a8rlBSYN

E6 Nursing Fundamentals Potter Perry 12e Part 6 p. 185-187

E6 Nursing Brunner Adult Health 3SA Vol 1 Part 1 p. 54-56

Practise the full DHS Staff Nurse - 2018 (Shift-2nd)

Attempt every question from this paper in a timed mock, then review the full solution for each one.