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","C","E"]
Explanation
Choice A Reason:
A negative Chvostek’s sign is not expected in a client with hypocalcemia. The Chvostek’s sign is a clinical indicator of hypocalcemia, where tapping the facial nerve triggers facial muscle twitching. A positive Chvostek’s sign indicates neuromuscular irritability due to low calcium levels. Therefore, a negative Chvostek’s sign would not be consistent with hypocalcemia.
Choice B Reason:
A positive Trousseau’s sign is a classic indicator of hypocalcemia. This sign is elicited by inflating a blood pressure cuff on the upper arm to a level above the systolic pressure for several minutes. The resultant carpopedal spasm (involuntary contraction of the hand and wrist muscles) is a positive Trousseau’s sign, indicating neuromuscular irritability due to low calcium levels.
Choice C Reason:
Muscle cramps are a common syptom of hypocalcemia. Low calcium levels increase neuromuscular excitability, leading to involuntary muscle contractions and cramps. These cramps can occur in various muscle groups, often causing significant discomfort.
Choice D Reason:
Abdominal distention is not typically associated with hypocalcemia. While abdominal distention can result from various gastrointestinal issues, it is not a direct symptom of low calcium levels. Hypocalcemia primarily affects neuromuscular function rather than causing abdominal distention.
Choice E Reason:
Tingling sensation around the lips, also known as perioral tingling, is a common symptom of hypocalcemia. This occurs due to increased neuromuscular irritability caused by low calcium levels, leading to sensations of tingling or numbness around the mouth.
Correct Answer is D
Explanation
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.