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 B
Explanation
Choice A reason:
Limiting the session to 1 hour is a practical approach when teaching older adults. Research indicates that older adults may have shorter attention spans and may become fatigued more quickly than younger individuals. Therefore, keeping the session to a manageable length ensures that the participants remain engaged and retain the information presented. Additionally, shorter sessions can help prevent cognitive overload, making it easier for older adults to absorb and process the material.
Choice B reason:
Providing an environment with minimal distractions is crucial for effective learning, especially for older adults. Distractions such as noise, poor lighting, and uncomfortable seating can hinder concentration and reduce the effectiveness of the educational program. By creating a calm and focused environment, the nurse can help older adults concentrate better on the material being taught. This approach aligns with best practices in adult education, which emphasize the importance of a conducive learning environment.
Choice C reason:
Presenting the information at a 10th-grade reading level is important to ensure that the material is accessible to all participants. Older adults may have varying levels of literacy and educational backgrounds, so using clear and straightforward language helps to ensure that everyone can understand the content. This approach also helps to avoid any potential feelings of frustration or inadequacy that might arise if the material is too complex. Simplifying the language used in educational materials is a widely recommended practice in health education.
Choice D reason:
Using brightly colored paper for written materials can enhance the learning experience for older adults. Bright colors can capture attention and make the materials more visually appealing. Additionally, older adults may have visual impairments, and using high-contrast colors can improve readability. This technique can help to ensure that the written materials are engaging and accessible, thereby enhancing the overall effectiveness of the educational program.
Correct Answer is C
Explanation
Choice A Reason
Increased heart rate during physical activity can be a common finding in clients who have been on bed rest for an extended period. This is due to deconditioning of the cardiovascular system. While it is important to monitor and address, it is not the most immediate concern compared to other potential complications.
Choice B Reason
Loss of appetite is another common issue in clients who have been on prolonged bed rest. It can lead to nutritional deficiencies and weight loss, which are significant concerns. However, it is not as urgent as other findings that might indicate more acute complications.
Choice C Reason
Left lower extremity tenderness is the most critical finding and should be identified as the priority. This symptom can indicate deep vein thrombosis (DVT), a serious condition that can lead to life-threatening complications such as pulmonary embolism if not promptly addressed. DVT is a common risk for clients who have been immobile for extended periods, making it a top priority for immediate
intervention.
Choice D Reason
Musculoskeletal weakness is expected in clients who have been on bed rest for several weeks. It results from muscle atrophy and deconditioning. While it is an important issue to address through rehabilitation and physical therapy, it does not pose an immediate threat to the client’s life compared to the risk of DVT.