Immediately before a bedside lumbar puncture, the nurse lead… | MyMerci
NCLEX-RN MOC
Question

Immediately before a bedside lumbar puncture, the nurse leads the team through the Universal Protocol "time-out." Which best describes the required components of the time-out?

Explanation
Universal Protocol requires the ENTIRE team to pause and verbally verify correct patient, correct procedure, correct site, correct position, and that equipment, imaging, and consent are present immediately before the procedure starts. The time-out must include all team members (active engagement), not just the nurse alone (1) or the provider alone (3). A single morning huddle (4) does NOT replace a procedure-specific time-out — each procedure requires its own time-out at the start.

In-depth explanation

Wrong-site, wrong-procedure, wrong-patient surgery is a sentinel event. The time-out is the final stop. The classic NCLEX trap is "the nurse already confirmed the patient earlier, so we can skip" — wrong; the time-out happens immediately before the procedure with the entire team actively participating.

Clinical scenario

The nurse is preparing for a bedside lumbar puncture. Per Joint Commission Universal Protocol, a pre-procedure time-out is performed by the entire team immediately before the procedure starts.

Key concepts

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For study reference only. Always follow current clinical guidelines and your institution’s protocols.