A nurse discovers an overlooked prescription for a type and crossmatch of a client who is scheduled for surgery. After notifying the laboratory, which of the following actions should the nurse take?

Prepare an incident report.

Cancel the client’s surgery.

Notify the operative team of the omission.

Give the client another blood consent form to sign.

Answer and Explanation

The Correct Answer is C

Choice A Reason

Preparing an incident report is an important step in documenting the oversight and ensuring that similar errors are prevented in the future. However, it is not the immediate priority when addressing the current situation. The primary focus should be on ensuring the client’s safety and the timely completion of the necessary preoperative procedures.

Choice B Reason

Canceling the client’s surgery is a drastic measure that should only be considered if there is no other way to ensure the client’s safety. Before taking such a step, the nurse should explore all other options to rectify the situation, such as notifying the operative team and the provider. This allows for a collaborative approach to determine the best course of action.

Choice C Reason

Notifying the operative team of the omission is the most appropriate action. This ensures that all relevant healthcare providers are aware of the situation and can take the necessary steps to address it. The operative team can then decide whether to proceed with the surgery as planned or to delay it until the type and crossmatch are completed. This collaborative approach prioritizes the client’s safety and ensures that all necessary precautions are taken.

Choice D Reason

Giving the client another blood consent form to sign is not directly related to addressing the overlooked prescription for a type and crossmatch. While obtaining informed consent is crucial, it does not resolve the immediate issue of ensuring that the client has the correct blood type and crossmatch completed before surgery. The focus should be on rectifying the oversight and ensuring that all preoperative requirements are met.

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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.

A. Observe the contours of the client’s abdomen using a penlight. B. Determine the presence of bowel sounds by using the diaphragm of the stethoscope. C. Systematically percuss the client’s abdomen. D. Use fingertips to lightly depress the right lower quadrant of the client’s abdomen. E. Press deeply into the client’s upper abdomen left of midline to detect aortic pulsation.

Correct Answer is A,B,C,D,E

Explanation

Choice A reason:

Observing the contours of the client’s abdomen using a penlight is the first step in the abdominal assessment. This step involves inspecting the shape, skin abnormalities, masses, and movement of the abdomen. It is essential to perform this step first to gather initial visual information about the abdomen’s condition before proceeding to other assessment techniques.

Choice B reason:

Determining the presence of bowel sounds by using the diaphragm of the stethoscope is the second step in the abdominal assessment. Auscultation should be performed before percussion and palpation to avoid altering the frequency and intensity of bowel sounds. This step helps assess the presence, frequency, and location of bowel sounds, as well as any vascular sounds.

Choice C reason:

Systematically percussing the client’s abdomen is the third step in the abdominal assessment. Percussion helps assess the presence of tympany or dullness, which can indicate the presence of air, fluid, or solid masses in the abdomen. This step provides valuable information about the underlying structures and any abnormalities.

Choice D reason:

Using fingertips to lightly depress the right lower quadrant of the client’s abdomen is the fourth step in the abdominal assessment. Light palpation helps assess the consistency, tenderness, and presence of any masses or rigidity in the abdomen. This step should be performed after percussion to avoid altering the findings.

Choice E reason:

Pressing deeply into the client’s upper abdomen left of midline to detect aortic pulsation is the fifth and final step in the abdominal assessment. Deep palpation helps assess the presence of any deep-seated masses and the aortic pulsation, which can provide information about the vascular status of the abdomen.

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A nurse discovers an overlooked prescription for a type and crossmatch of a client who is scheduled for surgery. After notifying the laboratory, which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to obtain a blood sample from an adult client for a capillary blood glucose test. Which of the following sites should the nurse select?

Correct Answer is D

Explanation

A nurse is assessing a client’s abdomen. In what order should the nurse complete the steps of the assessment? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is A,B,C,D,E

Explanation

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