# An alert adult in the preoperative holding area is scheduled for a right shoulder rotator cuff repair. After signing the consent form, the client tells the nurse, 'I thought my surgery was on my left shoulder.' Vital signs are stable, and transport to the operating room is planned within 15 minutes. Which actions should the nurse take at this time? Select all that apply. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=568911&lang=en > language: en > subject: System-Specific Assessments > category: ROR ## Question An alert adult in the preoperative holding area is scheduled for a right shoulder rotator cuff repair. After signing the consent form, the client tells the nurse, 'I thought my surgery was on my left shoulder.' Vital signs are stable, and transport to the operating room is planned within 15 minutes. Which actions should the nurse take at this time? Select all that apply. 1 Instruct the client that the consent form cannot be altered once signed and continue preparing for transport as scheduled. 2 Notify the surgeon of the client's statement and delay transport until the site discrepancy is resolved. 3 Have the client's spouse verify the surgical site and sign a new consent form on the client's behalf. 4 Ask the client when solid food and clear liquids were last consumed to confirm compliance with fasting guidelines. 5 Verify that the site marking on the client's shoulder matches the consent form and surgical schedule before transport. 6 Reassure the client that the surgical team will identify and correct any site error after anesthesia induction. ## Explanation The client's statement about the surgical site conflicts with the informed consent and must be resolved before transport, so the nurse notifies the surgeon and holds transport until clarification occurs. Confirming the operative site marking against the consent form and surgical schedule is a required safety check that prevents wrong-site surgery. Verifying the client's fasting status, including the last time food and clear liquids were consumed, is essential to reduce aspiration risk before anesthesia. Proceeding with transport without addressing the concern ignores an unresolved safety issue. Allowing a spouse to sign consent assumes decisional incapacity without supporting assessment data. Waiting until after anesthesia induction to correct the discrepancy delays action that must occur beforehand and violates safe surgical protocol. ## In-depth explanation Correct Answer Choices 2, 4, 5 Clinical Reasoning The client's statement about the surgical site conflicts with the informed consent and must be resolved before transport, so the nurse notifies the surgeon and holds transport until clarification occurs. Confirming the operative site marking against the consent form and surgical schedule is a required safety check that prevents wrong-site surgery. Verifying the client's fasting status, including the last time food and clear liquids were consumed, is essential to reduce aspiration risk before anesthesia. Proceeding with transport without addressing the concern ignores an unresolved safety issue. Allowing a spouse to sign consent assumes decisional incapacity without supporting assessment data. Waiting until after anesthesia induction to correct the discrepancy delays action that must occur beforehand and violates safe surgical protocol. Option Review - Incorrect — Continuing to prepare for transport without addressing the client's concern ignores an unresolved discrepancy that could result in wrong-site surgery. - Correct — Notifying the surgeon and holding transport allows the surgical team to verify the correct site before the client proceeds to the operating room. - Incorrect — Allowing a spouse to sign a new consent form assumes the client lacks decision-making capacity without any nursing assessment supporting that conclusion. - Correct — Confirming the timing of the client's last oral intake verifies compliance with preoperative fasting guidelines and reduces the risk of aspiration during anesthesia. - Correct — Comparing the site marking with the consent form and surgical schedule is a required safety check that helps prevent a wrong-site procedure. - Incorrect — Waiting until after anesthesia induction to address the site discrepancy delays a correction that must be resolved before the client enters the operating room. Sources 12026 NCLEX-RN Test Plan 2Joint Commission: Universal Protocol site marking 3ASA: Practice Guidelines for Preoperative Fasting ## Clinical scenario An alert adult in the preoperative holding area is scheduled for a right shoulder rotator cuff repair and has already signed the consent form. 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