A client asks a nurse how long a heat application should be left in place. Which response should the nurse make?

The nurse should use clarifying points made by the patient that are unclear and listening attentively while speaking slowly and clearly as communication techniques when performing a health history.

These techniques help the nurse to gather accurate and comprehensive information from the patient and to establish rapport and trust.

Choice A is wrong because avoiding silences can make the patient feel rushed or interrupted. Silences can be useful to allow the patient to think or express emotions.

Choice D is wrong because sitting approximately two feet away from the client may be too close and invade the personal space of the client. The nurse should maintain a comfortable distance of about 4 to 5 feet from the client, depending on the cultural norms and preferences of the client.

Choice E is wrong because asking the family member to complete the written form may not reflect the true health history of the client. The nurse should obtain the information directly from the client whenever possible, unless the client is unable or unwilling to provide it.

Notify the health care provider. The nurse should take this action first because the provider can prescribe appropriate interventions to prevent or minimize harm to the client.

The nurse should also inform the unit supervisor, document the error in the client’s medical record, and record the error on the appropriate quality improvement report, but these are not the priority actions.

Choice A is wrong because informing the unit supervisor is not the most urgent action. The supervisor can provide support and guidance to the nurse, but cannot prescribe interventions for the client.

Choice C is wrong because documenting the error in the client’s medical record is not the most urgent action.

The nurse should document the error after notifying the provider and assessing the client. Documentation should include the medication name, dose, route, time, client’s response, and actions taken.

Choice D is wrong because recording the error on the appropriate quality improvement report is not the most urgent action.

The nurse should record the error after notifying the provider and assessing the client. The report should include a factual description of what happened and what was done.