A nurse is collecting data from a client who is 1 day postoperative following a total hip arthroplasty. Which of the following findings is the priority for the nurse to report to the provider?
The client has had postoperative emesis.
The client reports pain as 8 on a scale of 0 to 10.
The client's urinary output is 30 mL over 1 hr.
The client has mottling in the affected leg.
The Correct Answer is D
A. Postoperative emesis is a common occurrence and may not be critical unless it persists or is accompanied by other concerning signs.
B. While an 8 out of 10 pain level is significant, it can be managed with appropriate interventions and does not indicate an immediate complication.
C. Urinary output of 30 mL over 1 hour is low but does not necessarily indicate a critical condition that requires immediate intervention.
D. Mottling in the affected leg is a serious finding that may indicate compromised circulation or a thromboembolic event, making it the priority for reporting to the provider.
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Correct Answer is A
Explanation
A. Autonomy refers to the right of individuals to make their own decisions regarding their healthcare, including the right to refuse treatment, which the nurse has supported in their response.
B. Fidelity involves being faithful to commitments made to patients, such as providing care and support, but does not directly pertain to the client's right to refuse treatment.
C. Beneficence focuses on promoting the well-being of the client, which may not align with the client’s decision to refuse treatment in this context.
D. Justice refers to fairness in healthcare and ensuring equitable treatment, but it does not address the specific right of the client to refuse treatment.
Correct Answer is A
Explanation
A. Reporting the incident to the manager of the pharmacy is the appropriate action to ensure that the medication error is addressed and investigated properly, as this can help prevent future occurrences.
B. Incident reports should not be placed in the client's medical record, as they are separate documents meant for internal review and quality improvement.
C. Documenting the doubled dose in the client's medical record does not fulfill the legal requirements for reporting medication errors and could mislead future care providers about the medication administration history.
D. Contacting the nurse from the previous shift may be necessary for understanding the situation, but the priority is to report the incident properly to ensure patient safety.