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 B
Explanation
Choice A: I use garlic for my menopausal symptoms.
Garlic is not typically used for menopausal symptoms. Common herbal supplements for menopause include black cohosh, red clover, and evening primrose oil. These herbs are known to help alleviate symptoms such as hot flashes and night sweats. Garlic, on the other hand, is more commonly associated with cardiovascular benefits, such as lowering blood pressure and cholesterol levels.
Choice B: I use ginger when I get car sick.
Ginger is well-known for its effectiveness in treating nausea and motion sickness. Studies have shown that ginger can help reduce symptoms of motion sickness, such as dizziness, vomiting, and cold sweats. It works by stabilizing digestive function and maintaining consistent blood pressure, which helps alleviate nausea. Therefore, using ginger for car sickness is a correct and effective use of the supplement.
Choice C: I take ginkgo biloba for a headache.
Ginkgo biloba is not typically used for headaches. It is more commonly used to improve cognitive function and circulation. While some studies suggest that ginkgo biloba may help reduce the frequency and severity of migraines due to its antioxidant properties, it is not a primary treatment for headaches. Other supplements, such as feverfew and butterbur, are more commonly recommended for headache relief.
Choice D: I take echinacea to control my cholesterol.
Echinacea is primarily used to boost the immune system and help fight infections, such as the common cold. There is no substantial evidence to support the use of echinacea for controlling cholesterol levels For cholesterol management, supplements like omega-3 fatty acids, plant sterols, and soluble fiber are more effective.
Correct Answer is C
Explanation
Choice A Reason:
Moving quickly to a position in front of the client is not recommended. This action could result in both the nurse and the client falling, potentially causing injury to both parties.
Choice B Reason:
Remaining upright as the client falls toward them is incorrect. This action does not provide adequate support or control, increasing the risk of injury to the client.
Choice C Reason:
Allowing the client to slide down their outstretched leg is the correct action. This technique helps control the fall and minimizes the risk of injury by providing a controlled descent to the floor.
Choice D Reason:
Placing their arms around the client to prevent the fall is not advisable. This action can lead to both the nurse and the client falling, which could result in injuries.