# A nurse assists during the immediate preprocedure phase for an adult scheduled for elective right-knee arthroscopy. Which actions support the Universal Protocol and perioperative safety? Select all that apply.

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> url: https://mymerci.kr/pages/nclex_q.php?qn_id=368587&lang=en  
> language: en  
> subject: System-Specific Assessments  
> category: ROR

## Question

A nurse assists during the immediate preprocedure phase for an adult scheduled for elective right-knee arthroscopy. Which actions support the Universal Protocol and perioperative safety? Select all that apply.

1

Have the circulating nurse mark the right knee after reviewing the schedule, then ask the surgeon to approve that mark after the client enters the operating room so the preprocedure workflow is not delayed

2

Use two identifiers and reconcile the intended procedure and site with the client, consent, schedule, and relevant records

3

Record procedure start and end times, but place time-out and count information only in a separate quality file that is not part of the client's operative documentation

4

Complete required sponge, sharps, and instrument counts at policy-defined points and reconcile discrepancies before the client leaves the operating room

5

Immediately before beginning, pause activity for an active team time-out that confirms the client, site, and procedure and resolves concerns

6

For a brief outpatient arthroscopy, replace the formal team time-out with the surgeon's earlier consent review and the circulating nurse's bedside confirmation

## Explanation

Preprocedure verification reconciles the correct client, procedure, and site across reliable sources and uses two identifiers (Choice 2). The licensed practitioner accountable for the procedure marks a lateralized site, involving the client when possible; the circulating nurse does not independently substitute for that practitioner (Choice 1). Required counts are completed at policy-defined points and discrepancies are resolved before the client leaves the operating room (Choice 4). An active time-out occurs immediately before the procedure begins, includes the immediate procedure team, confirms at least the client, site, and procedure, and pauses the procedure until concerns are resolved (Choice 5). A brief procedure is not exempt (Choice 6). Completion of the time-out and required counts is documented according to organizational policy; omitting it from the clinical record is not appropriate (Choice 3).

## In-depth explanation

Joint Commission Universal Protocol
1. Pre-procedure verification: identity (two identifiers + active confirmation), consent, H&P, imaging, equipment, antibiotic prophylaxis
2. Site marking: by the licensed provider PERFORMING the procedure (the surgeon), with client involvement when possible, unambiguous, visible after prep and drape
3. Time Out: immediately before incision, all team members present and engaged, other activity stopped, verbal verification:
- Correct client (two identifiers)
- Correct site/side
- Correct procedure
- Required equipment / implants available
- Antibiotic prophylaxis administered (within 60 min of incision)
- Imaging available and confirmed
- Any other safety concerns

Surgical Counts
- Initial (baseline) before incision
- Cavity closure
- Skin/wound closure
- Final count
- Items: sponges, sharps (needles, blades), instruments
- Discrepancies: STOP, search, x-ray if needed; do NOT release the client until resolved

Required for ALL Surgical Procedures
- Universal Protocol applies to every surgical procedure regardless of duration or setting (inpatient OR, outpatient OR, procedural areas)
- Documentation in the operative record

Wrong-Site / Wrong-Procedure Prevention
- Three components: pre-procedure verification, site marking, Time Out
- Most wrong-site events involve communication breakdown, distractions, missed steps, or schedule errors
- Speak up if any concern arises — every team member has Stop-the-Line authority

Memory Tip
"Verify-Mark-Time Out; Counts at every closure; Surgeon marks the site"

## Clinical scenario

Scenario
Adult client; elective right knee arthroscopy; nurse in pre-op holding/OR.

Action Map
1. Two-identifier verification + active confirmation; cross-check consent, H&P, schedule
2. Site marking by surgeon (NOT circulating nurse), with client involvement when possible
3. Time Out immediately before incision: all present, all stopped, verbal verification of identity/site/procedure/equipment/antibiotic/imaging
4. Counts: initial → cavity closure → skin closure → final
5. Document everything in the operative record

Avoid
- Circulating nurse marking the surgical site
- Skipping Time Out for "short" cases
- Documenting only start/end times

## Key concepts

- **Joint Commission Universal Protocol** — Standard for the prevention of wrong-site, wrong-procedure, and wrong-client surgery. Three components: (1) Pre-procedure verification of identity (two identifiers), consent, H&P, imaging, equipment, antibiotic prophylaxis; (2) Surgical site marking by the licensed provider performing the procedure, with client involvement when possible, unambiguous and visible after prep and drape; (3) Time Out immediately before incision with all team members present and engaged, other activity halted, verbal verification of correct client/site/procedure and other safety items. Required for ALL surgical procedures regardless of duration or setting.
- **Surgical Counts (Sponges, Sharps, Instruments)** — Standardized counting performed at defined points to prevent retained surgical items: initial (baseline) count before incision; counts at each cavity closure; counts at skin/wound closure; final count. Items counted: sponges, sharps (needles, blades), instruments. Discrepancies require STOP, search, additional counts, and intra-operative imaging if needed; the client must NOT leave the OR until the discrepancy is resolved. Both the circulating nurse and scrub team participate; counts are documented in the operative record.
- **Surgical Site Marking** — The intended surgical site must be marked by the LICENSED PROVIDER PERFORMING the procedure (the surgeon, not the nurse), prior to entering the OR. Client should be involved in the marking process when possible. Mark must be unambiguous, applied so it remains visible after prep and draping (typically the surgeon's initials at the site), and clearly distinguishes the correct side. Site marking is required for procedures involving laterality, multiple structures (fingers, toes), or multiple levels (spine).

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