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:
Electrical wires secured to baseboards are generally not considered a significant fall risk. Properly secured wires reduce the likelihood of tripping hazards compared to loose or exposed wires. Therefore, this is not a primary concern for fall risk.
Choice B Reason:
Taking antihypertensive medication can increase the risk of falls, especially in older adults. These medications can cause orthostatic hypotension, a condition where blood pressure drops significantly upon standing, leading to dizziness and an increased risk of falling. This makes it a critical factor to consider in fall risk assessments.
Choice C Reason:
Wearing rubber-sole shoes is typically recommended to prevent falls because they provide good traction and reduce the risk of slipping. However, if the soles are too thick or bulky, they can catch on carpets or other surfaces, potentially causing trips. Generally, rubber-sole shoes are considered safer than other types of footwear.
Choice D Reason:
A visual acuity of 20/40 indicates some level of visual impairment, but it is not severe. While reduced visual acuity can contribute to fall risk, it is not as significant as the risk posed by medications that affect blood pressure. Visual impairments should still be addressed, but they are not the most immediate concern in this context.
Correct Answer is C
Explanation
Choice A Reason:
Changing the dressing four times per day is excessive and not typically recommended. Most guidelines suggest changing the dressing once a day or as needed if it becomes soiled or wet. Over-frequent dressing changes can disrupt the healing process and increase the risk of infection.
Choice B Reason:
Applying tincture of benzoin prior to removing the dressing is not a standard practice for wound care. Tincture of benzoin is usually used to increase the adhesion of bandages or tapes, not for removing dressings. Using it inappropriately could cause skin irritation or damage.
Choice C Reason:
Cleaning from the incision to the surrounding skin is the correct method. This technique helps prevent the spread of bacteria from the surrounding skin into the incision site, reducing the risk of infection. Always use a sterile solution and clean gauze for this process.
Choice D Reason:
Using sterile gloves when removing the old dressing is important to maintain a sterile environment and prevent infection. However, this is a general practice and not specific to the wound care instructions provided in the question.