# A 70-year-old client is in the preoperative holding area for a scheduled knee arthroplasty and has not yet received sedation. The client is alert and oriented and states, "My left knee is the one being replaced." The signed surgical consent and the history and physical both identify left knee osteoarthritis. The operating room schedule lists a right knee arthroplasty, and a surgeon's site mark is present on the right knee. Transport has arrived and asks the nurse to send the client now because the schedule is running 30 minutes late. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617413&lang=en  
> language: en  
> subject: Advocacy  
> category: MOC

## Question

A 70-year-old client is in the preoperative holding area for a scheduled knee arthroplasty and has not yet received sedation. The client is alert and oriented and states, "My left knee is the one being replaced." The signed surgical consent and the history and physical both identify left knee osteoarthritis. The operating room schedule lists a right knee arthroplasty, and a surgeon's site mark is present on the right knee. Transport has arrived and asks the nurse to send the client now because the schedule is running 30 minutes late. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Condition

Select 1
Scheduling documentation error only
Client confusion about the operative side
Invalid informed consent
Unresolved wrong-site procedure risk

Actions to take

Select 2
Stop the transfer to the operating room
Remove the right mark and mark the left knee
Have the client sign a new right-knee consent
Send the client and raise it at the time-out
Notify the surgeon to reconcile all sources

Parameters to monitor

Select 2
Minutes of operating room delay
Client's stated side before sedation
Hours since last oral intake
Consent, schedule, and mark agreement
Preoperative blood pressure and heart rate

## Explanation

The client, consent, and history identify the left knee, while the schedule and the surgeon's mark identify the right, so a wrong-site risk exists until every source agrees. The nurse stops the transfer and notifies the surgeon to reconcile all sources while the client can still participate. The client's stated side before sedation and agreement of all documents and the mark are the parameters that confirm resolution. Assuming the schedule is simply wrong ignores the site mark that agrees with it.

## In-depth explanation

Quick answer
Unresolved wrong-site procedure risk; stop the transfer and notify the surgeon to reconcile all sources, then confirm the client's stated side before sedation and agreement of consent, schedule, and site mark.

Why this is correct
The Universal Protocol requires preprocedure verification, site marking by the licensed practitioner, and a time-out. Two sources disagree with three others, including a physical mark on the skin, so the discrepancy cannot be dismissed as a clerical error. Verification is most reliable before sedation, when the client can confirm the side.

Easy analogy or mental picture
Picture a GPS whose map says one exit while the driver and the road signs say another: you pull over and resolve it before driving, not after taking the exit.

Memory hook
Any mismatch before sedation = stop the line and bring in the surgeon.

NCLEX decision rule
When safety information conflicts, stop the process and escalate to the responsible practitioner; do not resolve the conflict alone or defer it to a later checkpoint.

Why the other choices are wrong
A scheduling error alone does not explain the site mark on the right knee. The client is alert, oriented, and consistent with the consent, so client confusion is not supported. The consent is signed and matches the client's understanding, so it is not invalid, and a new right-knee consent would legitimize the wrong side. Marking is done by the licensed practitioner performing the procedure, not by the nurse. Raising the issue at the time-out delays it until after sedation, when the client cannot participate. Delay time, fasting hours, and blood pressure are routine checks that do not confirm the correct site.

References
1The Joint Commission — Universal Protocol FAQPreprocedure verification and site marking must be completed and discrepancies resolved before the procedure.

## Clinical scenario

Scenario
Before sedation, the client, consent, and history and physical identify the left knee, but the operating room schedule and the site mark indicate the right knee, and transport is pressing to leave.

## Key concepts

- **Universal Protocol** — The Joint Commission process of preprocedure verification, site marking, and time-out to prevent wrong-site surgery.
- **Site marking** — An unambiguous mark on the procedure site made by the licensed practitioner who will perform it.
- **Time-out** — A final pause immediately before the procedure in which the whole team confirms client, procedure, and site.

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