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:
A client who has new onset of dyspnea 24 hours after a total hip arthroplasty should be seen first. Dyspnea, or difficulty breathing, can be a sign of a serious complication such as a pulmonary embolism, which is a medical emergency. Pulmonary embolism is a blockage in one of the pulmonary arteries in the lungs, usually caused by blood clots that travel to the lungs from the legs or other parts of the body. This condition requires immediate assessment and intervention to prevent life-threatening consequences.
Choice B reason:
A client who has a urinary tract infection and low-grade fever is a concern, but it is not as urgent as the client with new onset dyspnea. Urinary tract infections (UTIs) are common and can be managed with antibiotics and supportive care. While a low-grade fever indicates an infection, it does not pose an immediate threat to the client’s life. The nurse should still address this client’s needs, but it can be done after attending to the more urgent case.
Choice C reason:
A client who has acute abdominal pain of 4 on a scale from 0 to 10 should be assessed, but it is not as critical as the client with new onset dyspnea. Acute abdominal pain can have various causes, some of which may require urgent attention, but a pain level of 4 indicates moderate pain. The nurse should evaluate this client to determine the cause of the pain and provide appropriate interventions, but it can be done after addressing the more urgent case.
Choice D reason:
A client who has pneumonia and an oxygen saturation of 96% is stable at the moment. Oxygen saturation levels above 95% are generally considered acceptable in pneumonia patients. While pneumonia requires monitoring and treatment, the client’s current oxygen saturation level indicates that they are not in immediate respiratory distress. The nurse should continue to monitor this client and provide necessary care, but it can be done after attending to the more urgent case.
Correct Answer is B
Explanation
Choice A reason:
Attaching the restraints using a quick-release tie is essential for ensuring the safety of the client and the healthcare staff. A quick-release tie allows for the rapid removal of the restraints in case of an emergency, such as a fire or a sudden change in the client’s condition. This method is recommended by healthcare guidelines to ensure that restraints can be removed swiftly and safely.
Choice B reason:
Contacting the provider for a PRN (as needed) prescription for restraints is a necessary step to ensure that the use of restraints is authorized and documented. Restraints should only be used when absolutely necessary and with proper authorization to prevent misuse and to protect the client’s rights. This step ensures that the decision to use restraints is made with careful consideration and in accordance with legal and ethical standards.
Choice C reason:
Securing the restraints to a side rail on the client’s bed is not recommended. This practice can pose a significant risk to the client, as it can lead to injury if the client attempts to move or if the side rail is raised or lowered. Restraints should be secured to a part of the bed frame that does not move, such as the bed frame itself, to ensure the client’s safety.
Choice D reason:
Leaving enough room to fit three fingers between the restraints and the client’s wrist is incorrect. The correct practice is to leave enough room to fit two fingers between the restraints and the client’s wrist. This ensures that the restraints are not too tight, which could cause circulation problems or skin damage, and not too loose, which could allow the client to remove them.