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:
A family whose only child recently died due to cancer is experiencing a significant and traumatic loss. This type of loss is categorized as a situational loss because it is unexpected and not part of the normal life cycle. Situational losses are typically sudden and can cause profound grief and disruption in the family’s life. The death of a child is one of the most devastating events a family can endure, leading to intense emotional pain and a long grieving process.
Choice B Reason:
A family whose oldest child is moving away for college is experiencing a maturational loss. Maturational losses are those that occur as part of normal life transitions and developmental stages. These losses are anticipated and expected as individuals grow and progress through different phases of life. The transition of a child moving away for college is a common maturational loss, as it signifies a significant change in the family dynamic and the child’s development into adulthood.
Choice C Reason:
A family whose house was destroyed in a fire is dealing with a situational loss. This type of loss is unexpected and can have a severe impact on the family’s sense of security and stability. The destruction of a home involves not only the loss of physical property but also the emotional attachment and memories associated with the home. Recovering from such a loss requires significant emotional and practical adjustments.
Choice D Reason:
A family whose head of household lost their job is experiencing a situational loss. Job loss can lead to financial instability and stress, affecting the entire family’s well-being. This type of loss is not part of the normal developmental process and can create significant challenges for the family as they navigate the uncertainty and potential changes in their lifestyle.
Correct Answer is D
Explanation
Choice A Reason:
Leaving a transfer belt in place until the client returns from radiology is not recommended. The transfer belt is used to assist in moving the client safely, but it should be removed once the client is securely seated in the wheelchair to prevent discomfort or potential injury.
Choice B Reason:
Positioning the client so their weight is shifted forward is not a standard practice for transferring a client to a wheelchair. Proper positioning involves ensuring the client is seated comfortably and securely, with their weight evenly distributed to prevent falls or injuries.
Choice C Reason:
Lowering the footplates before transferring the client from the bed is incorrect. The footplates should be raised to allow the client to safely transfer from the bed to the wheelchair without tripping or getting their feet caught.
Choice D Reason:
Backing the wheelchair into the elevator is the correct action. This ensures that the client enters the elevator facing forward, which is safer and more comfortable for the client. It also allows the nurse to maintain better control of the wheelchair during the transition.