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 Reason:
Refrigerating the solution before irrigation is not recommended. The solution should be at room temperature to avoid causing discomfort or vasoconstriction, which can impede the healing process.
Choice B Reason:
Administering an analgesic medication 5 minutes before starting irrigation is correct. This action helps manage the client’s pain during the procedure, ensuring comfort and compliance.
Choice C Reason:
Using one pair of gloves for both dressing removal and irrigation is incorrect. The nurse should use separate pairs of gloves to prevent cross-contamination and maintain aseptic technique.
Choice D Reason:
Using a syringe with a catheter for wound irrigation is correct practice. This method allows for controlled and directed irrigation, ensuring the wound is properly cleaned.
Correct Answer is C
Explanation
Choice A Reason:
Urinary frequency is not typically associated with allergic reactions. It is more commonly related to urinary tract infections, diabetes, or other conditions affecting the urinary system. Therefore, it is not an indication of a mild allergic reaction.
Choice B Reason:
Tinnitus, or ringing in the ears, is not a common symptom of an allergic reaction. It is usually associated with conditions affecting the auditory system, such as exposure to loud noises, ear infections, or certain medications. Thus, it does not indicate a mild allergic reaction.
Choice C Reason:
Urticaria, also known as hives, is a common symptom of a mild allergic reaction. It presents as red, itchy welts on the skin that can vary in size and shape. Urticaria occurs when the body’s immune system reacts to an allergen, releasing histamines that cause the characteristic rash.
Choice D Reason:
A sore throat can be a symptom of various conditions, including infections like the common cold or strep throat. While it can occur in some allergic reactions, it is not a primary indicator of a mild allergic reaction. More common symptoms of mild allergic reactions include hives, itching, and nasal congestion.