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
Eyelashes that curl slightly outward are a normal finding in an eye assessment. This natural curl helps protect the eyes from debris and sweat, and it also aids in the distribution of tears across the eye surface. Eyelashes that curl outward are typical and expected in a healthy individual.
Choice B Reason
Corneas with an opaque appearance are not a normal finding. The cornea should be clear and transparent, allowing light to pass through to the retina. An opaque cornea can indicate various conditions such as corneal edema, scarring, or infection. Therefore, this finding would be abnormal and warrant further investigation.
Choice C Reason
Eyelids that blink involuntarily 30 to 35 times per minute are not within the normal range. The average blink rate for a healthy adult is approximately 15 to 20 times per minute. A significantly higher blink rate could indicate an underlying condition such as dry eye syndrome, blepharospasm, or other neurological issues.
Choice D Reason
Pupils that are 8 to 9 mm in diameter are abnormally large. The normal pupil size ranges from 2 to 4 mm in bright light and 4 to 8 mm in dim light. Pupils that are consistently larger than this range could indicate a condition such as mydriasis, which can be caused by various factors including medications, trauma, or neurological disorders.
Correct Answer is B
Explanation
Choice A Reason:
Adjusting the head of the bed to 90° is a recommended practice for clients with dysphagia. This position helps facilitate swallowing and reduces the risk of aspiration by using gravity to assist the passage of food and liquids from the mouth to the stomach.
Choice B Reason:
Drinking thickened juice with a straw is not recommended for clients with dysphagia. Using a straw can increase the speed and force with which liquids enter the mouth, making it harder to control the swallow and increasing the risk of aspiration. Thickened liquids are designed to move more slowly, giving the client more control over swallowing, but using a straw negates this benefit.
Choice C Reason:
Taking frequent breaks while eating is a good practice for clients with dysphagia. It allows them to chew and swallow food thoroughly, reducing the risk of choking and aspiration. This practice also helps prevent fatigue, which can impair swallowing function.
Choice D Reason:
Tucking the chin when swallowing, also known as the chin-tuck maneuver, is a common technique used to help clients with dysphagia. This action helps protect the airway by narrowing the entrance to the larynx and directing the food or liquid down the esophagus.