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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is D
Explanation
Choice A Reason:
The National League for Nursing (NLN) is an organization that focuses on nursing education and the development of nurse educators. While it plays a significant role in advancing the quality of nursing education, it does not define the nursing scope of practice. The NLN provides resources, professional development, and accreditation for nursing programs, but the legal scope of practice is determined by state laws and regulations.
Choice B Reason:
The Joint Commission is an independent, non-profit organization that accredits and certifies healthcare organizations and programs in the United States. Its primary role is to ensure that healthcare organizations meet certain performance standards to provide safe and effective care. While the Joint Commission sets standards for healthcare quality and safety, it does not define the nursing scope of practice. Its focus is on organizational accreditation rather than individual professional practice.
Choice C Reason:
The Patients Bill of Rights is a document that outlines the rights and responsibilities of patients within the healthcare system. It aims to ensure that patients receive fair and respectful treatment and have a voice in their care decisions. Although it is important for protecting patient rights, it does not define the nursing scope of practice. The Patients Bill of Rights addresses patient care from a consumer perspective rather than a professional regulatory standpoint.
Choice D Reason:
State-based Nurse Practice Acts are laws enacted by state legislatures that define the scope of practice for nurses within that state. These acts outline the legal parameters for nursing practice, including what tasks and responsibilities nurses are authorized to perform. They are designed to protect public health and safety by ensuring that nurses provide care within their level of competence and training. The Nurse Practice Acts are the primary source for defining the nursing scope of practice and are enforced by state boards of nursing.
Correct Answer is ["A","E"]
Explanation
Choice A Reason:
Cutting the opening of the pouch 1/8 inch larger than the stoma is crucial to ensure a proper fit and to prevent skin irritation. The stoma can change size, especially in the initial weeks post-surgery, so it is important to measure it regularly and adjust the pouch opening accordingly. This practice helps in maintaining a secure seal and protecting the skin around the stoma from exposure to waste.
Choice B Reason:
Placing a piece of gauze over the stoma while changing the pouch can help in absorbing any output and keeping the area clean during the change. However, this is more of a practical tip rather than a strict instruction for ostomy care. It is not essential for all patients and may vary based on individual preferences and needs.
Choice C Reason:
Expecting the stoma to turn a purple-blue color as it heals is incorrect. A healthy stoma should be pink or red and moist. A purple-blue color can indicate poor blood supply or other complications and should be reported to a healthcare provider immediately. Proper stoma care includes monitoring its color and seeking medical advice if any unusual changes occur.
Choice D Reason:
Using povidone-iodine to clean around the stoma is not recommended. The skin around the stoma should be cleaned with mild soap and water or just water. Povidone-iodine can be too harsh and may cause irritation or allergic reactions. It is important to use gentle cleaning methods to maintain skin integrity and prevent complications.
Choice E Reason:
Emptying the ostomy pouch when it becomes one-third full of contents is a standard practice to prevent leaks and maintain comfort. Overfilling the pouch can lead to detachment from the skin and potential skin irritation. Regular emptying helps in managing the ostomy effectively and maintaining hygiene.