During change-of-shift report, a nurse discovers they overlooked a prescription for a type and cross-match of a client who is to have surgery the next day. Which of the following actions should the nurse take first?
Inform the provider of the delay in obtaining the type and cross-match.
Document the incident in the client’s medical record.
Prepare an incident report for risk management.
Obtain the client’s type and cross-match.
The Correct Answer is D
Choice A Reason:
Informing the provider of the delay in obtaining the type and cross-match is important for keeping the healthcare team informed. However, this action should follow the immediate step of obtaining the type and cross-match to ensure the client has compatible blood available for surgery. Communication with the provider is crucial but secondary to addressing the immediate need.
Choice B Reason:
Documenting the incident in the client’s medical record is necessary for maintaining accurate records and ensuring continuity of care. However, this action should be performed after the immediate need for obtaining the type and cross-match is addressed. Accurate documentation is essential but not the first priority in this situation.
Choice C Reason:
Preparing an incident report for risk management is important for identifying and addressing potential system issues that led to the oversight. However, this action is not the immediate priority. The primary focus should be on obtaining the type and cross-match to ensure the client’s safety during surgery. Incident reporting can be done after the immediate needs are met.
Choice D Reason:
Obtaining the client’s type and cross-match is the first action the nurse should take because it ensures that the client will have compatible blood available for transfusion if needed during surgery. This step directly addresses the immediate clinical need and prioritizes the client’s safety and readiness for surgery.
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Correct Answer is D
Explanation
Choice A: Constricted Pupils
Constricted pupils, also known as miosis, are typically associated with opioid use or exposure to certain toxins. While opioids are sometimes used to manage chronic pain, constricted pupils are not a direct result of chronic pain itself. Therefore, this option is not the correct answer.
Choice B: Bradycardia
Bradycardia, or a slower than normal heart rate, is not commonly associated with chronic pain. Chronic pain can lead to various physiological responses, but a significant reduction in heart rate is not typically one of them. This makes bradycardia an unlikely choice.
Choice C: Diaphoresis
Diaphoresis, or excessive sweating, is more commonly associated with acute pain or stress responses rather than chronic pain. Chronic pain tends to have more long-term psychological and physiological effects rather than immediate autonomic responses like sweating. Hence, this is not the correct answer.
Choice D: Depression
Depression is a well-documented consequence of chronic pain. Chronic pain can significantly impact a person’s quality of life, leading to feelings of hopelessness, sadness, and a lack of interest in daily activities. The persistent nature of chronic pain often results in psychological distress, making depression a common finding in individuals suffering from chronic pain.
Correct Answer is D
Explanation
Choice A Reason:
Telling the client to ask their provider if they recommend traditional Chinese medicine (TCM) is a cautious approach, but it may not fully address the client’s interest in exploring alternative treatments. While it is important for the client to discuss their treatment options with their provider, the nurse can take a more proactive role by facilitating access to TCM practitioners.
Choice B Reason:
Suggesting that the client try the prescribed medication before choosing an alternative may come across as dismissive of the client’s preferences. It is important to respect the client’s autonomy and support their informed decision-making. Encouraging the client to explore TCM while also considering the prescribed medication can be a more balanced approach.
Choice C Reason:
Stating that the FDA regulates traditional Chinese medicine is inaccurate. The FDA does not regulate TCM in the same way it regulates conventional pharmaceuticals. TCM practices and products are subject to different regulatory standards, and it is important for the nurse to provide accurate information about the regulatory status of TCM.
Choice D Reason:
Offering to arrange a referral to a practitioner of traditional Chinese medicine is an appropriate and supportive response. This approach respects the client’s interest in TCM and facilitates access to qualified practitioners who can provide safe and effective care. It also ensures that the client receives comprehensive information about their treatment options.
