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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is D
Explanation
Choice A Reason:
The pad of the thumb is not typically recommended for capillary blood glucose testing. While it is possible to obtain a blood sample from the thumb, it is less commonly used due to the thickness of the skin and the presence of more nerve endings, which can make the procedure more painful. Fingertips, especially the sides of the fingers, are preferred because they have a rich supply of capillaries and are less painful.
Choice B Reason:
The pinna of the ear is not a standard site for capillary blood glucose testing. This area is not commonly used because it is less accessible and may not provide a reliable blood sample. The fingertips are more practical and provide consistent results due to their capillary density.
Choice C Reason:
The pad of the big toe is also not a common site for capillary blood glucose testing. Similar to the thumb, the skin on the toes is thicker and may be more painful to puncture. Additionally, the toes are less convenient and hygienic for frequent testing compared to the fingers.
Choice D Reason:
The side of the ring finger is one of the most recommended sites for capillary blood glucose testing. This area is preferred because it has a good capillary supply, making it easier to obtain an adequate blood sample. Additionally, the sides of the fingers are less sensitive than the pads, reducing discomfort during the procedure. Using the sides of the fingers also helps to avoid the more sensitive central part of the fingertip.
Correct Answer is B
Explanation
Choice A: Physical therapist
Physical therapists primarily focus on improving a patient’s physical function, mobility, and strength. They work on activities such as walking, balance, and coordination1. While they play a crucial role in the rehabilitation of clients with traumatic brain injuries, their expertise is not specifically centered on activities of daily living (ADLs) like using eating utensils.
Choice B: Occupational therapist
Occupational therapists specialize in helping clients regain the ability to perform ADLs, which include tasks such as eating, dressing, and bathing. They use therapeutic techniques to improve fine motor skills, coordination, and cognitive function, which are essential for relearning how to use eating utensils. Their goal is to enhance the client’s independence and quality of life by enabling them to perform everyday activities.
Choice C: Speech-language pathologist
Speech-language pathologists focus on communication disorders and swallowing difficulties. They work with clients to improve speech, language, and cognitive-communication skills. While they are essential for addressing issues related to speech and swallowing, they do not typically focus on the motor skills required for using eating utensils.
Choice D: Social worker
Social workers provide support and resources to help clients and their families cope with the emotional, social, and financial aspects of a traumatic brain injury. They assist with discharge planning, accessing community resources, and providing counseling. However, they do not provide direct rehabilitation services related to the use of eating utensils.