A nurse is caring for a patient receiving IV therapy in the left forearm and notices that the site is red, swollen, and warm.
What action should the nurse take first?

The correct answer is choice d. Auscultate lung fields.

Choice A rationale:

Cupping hands and tapping on the patient’s chest is part of the chest percussion technique, which helps to loosen mucus. However, it is not the first step. Before performing any physical intervention, the nurse must assess the patient’s current respiratory status.

Choice B rationale:

Positioning the patient so that the lung area to be drained is above the trachea is part of postural drainage. This step is crucial but should be done after assessing the patient’s lung fields to determine the areas that need drainage.

Choice C rationale:

Providing mouth care is important for overall hygiene and to prevent infection, especially in patients with respiratory conditions. However, it is not directly related to the immediate assessment and intervention for chest physiotherapy.

Choice D rationale:

Auscultating lung fields is the first step because it allows the nurse to assess the patient’s respiratory status and identify areas with abnormal breath sounds, which will guide the subsequent interventions like chest percussion, vibration, and postural drainage. This assessment ensures that the interventions are targeted and effective.

The correct answer is Choice A: Refer questions to the nursing supervisor.

Choice A rationale: By referring inquiries from other nurses to the nursing supervisor, the nurse maintains patient privacy and upholds healthcare privacy regulations, such as the Health Insurance Portability and Accountability Act (HIPAA). These regulations mandate that patient information should only be disclosed on a need-to-know basis. Referring questions to the nursing supervisor ensures that any information released is managed through the appropriate channels and protects the patient's confidentiality.

Choice B rationale: Transferring calls directly to the patient's room could infringe on their privacy and disrupt their care or rest. It is not the nurse's role to decide if the patient should be disturbed, and doing so may potentially compromise patient care and satisfaction.

Choice C rationale: Acknowledging that the person is a patient on the unit can violate confidentiality rules, as it confirms the individual's presence in the hospital and could lead to speculation about their condition. Nurses must maintain patient privacy by refraining from sharing any information, even if it seems harmless.

Choice D rationale: Contacting the patient's provider does not directly address the issue of handling inquiries from other nurses and could breach confidentiality if the provider discloses information without the patient's consent. Additionally, the provider may not be immediately available, which would delay addressing the inquiries and potentially expose the patient's privacy further.