A client arrives in the preoperative holding area for a scheduled left knee arthroscopy. The surgeon marked the operative site earlier that morning per policy. Another team member gave the client a sedative, and the client is now drowsy but arousable. The surgeon is finishing another case and is not yet present. Which actions correctly fulfill the Universal Protocol from preprocedure verification through the final time-out before incision? Select all that apply.
Select All That Apply
Choose your responses, then check the answer.
Explanation
Safe procedure verification depends on independent identity checks using two identifiers, reconciliation of consent and documentation with the marked site, and an active final time-out performed by the complete team immediately before incision. Sedation does not eliminate the need for identity verification; the nurse still confirms responses against the record. Site marking authority remains with the licensed practitioner performing the procedure and cannot shift to nursing staff or family members regardless of scheduling delays. Verbal or phone confirmation of the site from someone not physically present does not substitute for direct visual verification during time-out, and a family member's statement is not an accepted identifier or site-verification source in this process.
Clinical Reasoning Safe procedure verification depends on independent identity checks using two identifiers, reconciliation of consent and documentation with the marked site, and an active final time-out performed by the complete team immediately before incision. Sedation does not eliminate the need for identity verification; the nurse still confirms responses against the record. Site marking authority remains with the licensed practitioner performing the procedure and cannot shift to nursing staff or family members regardless of scheduling delays. Verbal or phone confirmation of the site from someone not physically present does not substitute for direct visual verification during time-out, and a family member's statement is not an accepted identifier or site-verification source in this process.
Option Review
Correct — Confirming identity with name and date of birth, even though the client is drowsy, uses two independent identifiers required before any invasive procedure and protects against wrong-patient errors.
Incorrect — A phone confirmation from the surgeon does not replace visual verification of the marked site during an active time-out involving the entire team present at the bedside.
Incorrect — A family member's statement about the surgical site is not an approved identifier or verification method; the mark itself and medical record must be checked instead.
Incorrect — Site marking is the responsibility of the licensed practitioner performing the procedure and cannot be delegated to the circulating nurse, even when the surgeon is delayed.
Correct — Reconciling the consent form with the documented procedure and site ensures that all sources agree before the client leaves the holding area for surgery.
Correct — An active final time-out with the full team confirms the correct client, procedure, and site immediately before incision, fulfilling the last Universal Protocol step.
Sources
12026 NCLEX-RN Test Plan
2Joint Commission: Universal Protocol site marking
3Joint Commission: Right patient, right care
A client is in the preoperative holding area for a scheduled left knee arthroscopy after the surgeon marked the site that morning. Before time-out, the nurse learns another team member sedated the client for anxiety and the surgeon has not yet arrived.