A nurse is caring for a client.

Exhibits

The nurse is assessing the client.

Select the 4 findings that require immediate follow-up.

A. Fill out an incident report. While completing an incident report is necessary for documentation and quality improvement, it is not the priority action. The nurse must first assess the client's condition to address any immediate risks.
B. Report the incident to the nurse manager. Informing the nurse manager is important for accountability and follow-up, but client safety and assessment come first before escalating the issue to management.
C. Notify the provider. The provider should be informed after the nurse has assessed the client and gathered relevant data such as vital signs. This allows the provider to make informed decisions about further treatment or monitoring.
D. Measure the client's vital signs. Assessing the client is the first priority following a medication error to identify any adverse effects. Vital signs provide immediate data on the client’s physiological status and guide urgent interventions if needed.

A. Request an interpreter of a different sex from the client. The interpreter's sex should be based on the client’s cultural preferences, not assumed by the nurse. This decision should be made to promote comfort and cultural sensitivity.
B. Request a family member or friend to interpret information for the client. This is not recommended, especially for medical discussions, as it may lead to misinterpretation, breaches of confidentiality, and biased communication.
C. Direct attention toward the interpreter when speaking to the client. The nurse should speak directly to the client, not the interpreter, to maintain a therapeutic relationship and respect for the client.
D. Review the facility policy about the use of an interpreter. This is the most appropriate initial action. Each facility typically has specific guidelines and procedures for accessing qualified medical interpreters, which the nurse should follow to ensure accurate and ethical communication.