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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?

A.

Inform the provider of the delay in obtaining the type and cross-match.

B.

Document the incident in the client’s medical record.

C.

Prepare an incident report for risk management.

D.

Obtain the client’s type and cross-match.

Answer and Explanation

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 D

Explanation

Choice A Reason

Allowing the client to hear running water while attempting to void can sometimes help stimulate urination through the power of suggestion. This method is non-invasive and can be effective for some patients. However, it may not be sufficient for a client who is 6 hours postoperative and experiencing significant difficulty voiding. In such cases, more direct intervention may be necessary to prevent complications like bladder distension or urinary retention.

Choice B Reason

Encouraging fluid intake up to 1,000 mL daily is generally good advice for maintaining hydration and promoting urinary function. However, in the immediate postoperative period, especially within the first 6 hours, the focus should be on addressing the acute issue of urinary retention. Increasing fluid intake alone may not resolve the problem and could potentially exacerbate bladder distension if the client is unable to void.

Choice C Reason

Providing the client a bedpan while lying supine is a practical approach to assist with urination, especially if the client is unable to get out of bed. However, the supine position is not the most conducive for voiding, as it can make it more difficult for the bladder to empty completely. This method might not be effective for a client experiencing significant difficulty voiding postoperatively.

Choice D Reason

Inserting an indwelling urinary catheter and connecting it to gravity drainage is the most appropriate action for a client who is 6 hours postoperative and having difficulty voiding. This intervention directly addresses the issue of urinary retention by ensuring that the bladder is emptied, thereby preventing complications such as bladder distension, urinary tract infections, and potential kidney damage. It is a standard practice in postoperative care when less invasive methods are ineffective.

Correct Answer is D

Explanation

Choice A: Constricted Pupils

Constricted pupils, also known as miosis, are typically associated with opioid use or exposure to certain toxins. While opioids are sometimes used to manage chronic pain, constricted pupils are not a direct result of chronic pain itself. Therefore, this option is not the correct answer.

Choice B: Bradycardia

Bradycardia, or a slower than normal heart rate, is not commonly associated with chronic pain. Chronic pain can lead to various physiological responses, but a significant reduction in heart rate is not typically one of them. This makes bradycardia an unlikely choice.

Choice C: Diaphoresis

Diaphoresis, or excessive sweating, is more commonly associated with acute pain or stress responses rather than chronic pain. Chronic pain tends to have more long-term psychological and physiological effects rather than immediate autonomic responses like sweating. Hence, this is not the correct answer.

Choice D: Depression

Depression is a well-documented consequence of chronic pain. Chronic pain can significantly impact a person’s quality of life, leading to feelings of hopelessness, sadness, and a lack of interest in daily activities. The persistent nature of chronic pain often results in psychological distress, making depression a common finding in individuals suffering from chronic pain.

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