A nurse has initiated an incident report for a missed dose of medication on a client that caused no harm to the client. Which of the following responses by the nurse manager indicates the use of just culture?

The client is most at risk of developing atelectasis and paralytic ileus.

Rationale:

1. Atelectasis – The client has shallow breathing and received IV morphine, which can suppress respiratory effort. Postoperative clients, especially those with abdominal surgery, are at higher risk for atelectasis due to pain-related splinting and immobility.

2. Paralytic Ileus – The client has hypoactive bowel sounds at both assessments, indicating delayed return of bowel function postoperatively. This is common after abdominal surgery, especially with opioid use, and can lead to paralytic ileus.

• Urinary tract infection (UTI) – The client has voided 350 mL of clear yellow urine, indicating normal urinary function post-catheter removal.
• Delayed wound healing – There is no sign of wound complications (dressing remains dry and intact).
• Deep vein thrombosis (DVT) – No signs of unilateral swelling, redness, or pain, and the client is wearing sequential compression devices to prevent DVT.

A. Consult the social worker to speak with the client about support groups. While a social worker can be a valuable resource, advocacy involves the nurse directly supporting the client rather than referring them to another professional as the primary action.
B. Help the client make decisions about their treatment by providing them with your opinions. Advocacy means ensuring the client has accurate, unbiased information to make informed decisions, not influencing them with personal opinions.
C. Provide the client with a computer to look up questions they have about their diagnosis. While access to information is important, the nurse should provide evidence-based resources and ensure the client receives accurate, professional guidance.
D. Avoid discussing alternative treatments that may have the potential to harm the client. Advocacy includes ensuring the client is aware of safe and effective treatment options while protecting them from misinformation or potentially harmful alternatives.