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: Seat the client in a chair for 30 minutes prior to applying the stockings.
Seating the client in a chair for 30 minutes before applying the stockings is not necessary. In fact, it is recommended to apply antiembolic stockings while the client is in a supine position to prevent blood from pooling in the legs. This ensures that the stockings fit properly and provide the intended compression to promote venous return.
Choice B: Measure the length of the client’s leg from the heel to the gluteal fold.
Measuring the length of the client’s leg from the heel to the gluteal fold is essential for ensuring the correct fit of knee-length antiembolic stockings. Proper measurement helps in selecting the right size, which is crucial for the stockings to be effective in preventing deep vein thrombosis (DVT) by promoting blood circulation. Incorrectly sized stockings may either be too tight, causing discomfort and impaired circulation, or too loose, failing to provide adequate compression.
Choice C: Instruct the client to point their toes while applying the stockings.
Instructing the client to point their toes while applying the stockings is not a standard practice. Instead, the nurse should gather the stocking material and gently roll it over the foot and up the leg, ensuring it is evenly distributed and free of wrinkles. This method helps in applying the stockings smoothly and effectively without causing discomfort or improper fit.
Choice D: Roll the top of the client’s stockings down to just below the knee.
Rolling the top of the stockings down to just below the knee is incorrect and can lead to a tourniquet effect, which can impede blood flow and increase the risk of DVT. The stockings should be applied smoothly and should extend to their full length without being rolled down to ensure proper compression and effectiveness.
Correct Answer is C
Explanation
Choice A reason:
Preventive care focuses on measures taken to prevent diseases, rather than treating them. This includes vaccinations, screenings, and lifestyle counseling. Emergency care, which deals with immediate and acute medical conditions, does not fall under preventive care. Preventive care aims to reduce the incidence of diseases and conditions before they occur, whereas emergency care addresses urgent health issues that require immediate attention.
Choice B reason:
Tertiary care involves specialized consultative care, usually on referral from primary or secondary medical care personnel. It includes advanced medical investigation and treatment, such as cancer management, neurosurgery, cardiac surgery, and other complex medical and surgical interventions. Emergency care, which provides immediate treatment for acute illnesses and injuries, is not categorized under tertiary care. Tertiary care is more about long-term and specialized treatment.
Choice C reason:
Primary care is the first point of contact for individuals entering the healthcare system. It includes general health care services provided by physicians, nurse practitioners, and physician assistants. Primary care focuses on overall health maintenance, disease prevention, and the treatment of common illnesses and conditions. Emergency care, which deals with acute and urgent medical conditions, is not part of primary care. Primary care providers may refer patients to emergency care when immediate attention is needed.
Choice D reason:
Secondary care involves specialized medical services provided by specialists after referral from a primary care provider. It includes services such as cardiology, dermatology, and orthopedics. Emergency care, which provides immediate treatment for acute medical conditions, is considered part of secondary care. Emergency departments in hospitals are staffed by specialists who provide urgent and critical care to patients.