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 A
Explanation
Choice A Reason:
Airborne precautions are necessary for clients with tuberculosis (TB) because TB is an airborne disease. It is transmitted through tiny droplets released into the air when an infected person coughs, sneezes, or talks. These precautions include placing the client in a negative pressure room, using N95 respirators for healthcare workers, and ensuring the client wears a surgical mask when outside their room. These measures help prevent the spread of TB to others.
Choice B Reason:
Protective precautions, also known as reverse isolation, are used to protect immunocompromised patients from infections. These precautions are not appropriate for a client with TB, as the primary concern is preventing the spread of TB from the infected client to others, not protecting the client from external infections.
Choice C Reason:
Contact precautions are used for infections that are spread by direct or indirect contact with the patient or their environment, such as MRSA or C. difficile. TB is not spread through contact but through airborne particles, so contact precautions are not sufficient for preventing the transmission of TB.
Choice D Reason:
Droplet precautions are used for diseases that are spread through large respiratory droplets, such as influenza or pertussis. While TB is a respiratory disease, it is spread through much smaller airborne particles that can remain suspended in the air for longer periods, making airborne precautions necessary instead of droplet precautions.
Correct Answer is B
Explanation
Choice A Reason:
Going to bed at a different time each night can disrupt the body’s natural circadian rhythm, leading to poor sleep quality and increased stress levels. Consistent sleep schedules are crucial for maintaining good sleep hygiene and reducing stress. Regular sleep patterns help regulate the body’s internal clock, improve sleep quality, and enhance overall well-being.
Choice B Reason:
Attending a support group each week can provide emotional support, reduce feelings of isolation, and offer practical advice for managing stress. Support groups create a sense of community and belonging, which can be very beneficial for mental health. Sharing experiences and coping strategies with others who are going through similar situations can help individuals feel understood and supported.
Choice C Reason:
Doing tasks oneself rather than delegating can lead to increased stress and burnout, especially if the workload is overwhelming. Effective stress management includes recognizing when to delegate tasks to others. Delegation helps distribute the workload, prevents burnout, and allows individuals to focus on more critical tasks. It also fosters teamwork and collaboration.
Choice D Reason:
Exercising for 1 hour each week is beneficial, but it may not be sufficient for effective stress management. The American Heart Association recommends at least 150 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous activity per week for optimal health benefits. Regular physical activity helps reduce stress, improve mood, and enhance overall physical and mental health.