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 D
Explanation
Choice A reason:
“It is not necessary to tell the doctor about the herbal supplements I take.” This statement is incorrect. It is crucial to inform the doctor about all medications, including herbal supplements, as they can interact with prescription medications and cause adverse effects. Herbal supplements can strongly affect the body and may not work well with prescription medicines.
Choice B reason:
“I am less likely to experience an allergic reaction from medications I have taken before.” This statement is incorrect. Allergic reactions can occur even if the medication has been taken before without any issues. The immune system can develop sensitivities over time, and an allergic reaction can happen at any point.
Choice C reason:
“If a medication makes me feel nauseated, then I should stop taking it for 1 week.” This statement is incorrect. Stopping a medication without consulting a healthcare provider can be dangerous. It is important to discuss any side effects with a healthcare provider to determine the best course of action. Stopping a medication abruptly can lead to worsening of the condition or other complications.
Choice D reason:
“My medications could interact with foods that I eat.” This statement is correct. Certain foods can interact with medications and affect their absorption, effectiveness, or cause adverse effects. For example, grapefruit juice can interact with statins and increase the risk of side effects. It is important to be aware of potential food-drug interactions and follow the healthcare provider’s advice on medication administration.
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.