A nurse is preparing to administer medication to a client who has Crohn's disease. The client states, "I want to skip this dose of my medication. I am too tired to take it." Which of the following actions should the nurse take?

The correct answer is C.

Choice A: Take extra wheelchairs to the emergency department While having extra wheelchairs available can be helpful in a disaster situation, it is not the primary responsibility of the PACU charge nurse. The logistics of equipment distribution would typically be managed by a different team or department.

Choice B: Send PACU assistive personnel to assist with triage Triage is a critical part of disaster response, but it is typically performed by trained emergency department personnel or those with specific training in disaster triage. PACU personnel should focus on their area of expertise, which is post-anesthesia care.

Choice C: Identify stable clients for transfer to a surgical unit This is the correct action. By identifying stable clients for transfer, the PACU charge nurse can free up space for incoming patients who may require immediate post-operative care. This action helps to ensure that the PACU is ready to receive patients who are likely to come from the emergency department after immediate lifesaving interventions.

Choice D: Report to the command center for further instructions While communication with the command center is important in a disaster situation, the PACU charge nurse’s primary responsibility is to manage the care environment and patient flow within their specific unit. Other teams or personnel would likely handle tasks like reporting to the command center.

The correct answer is choice A: Provide information about alternate birth control methods.

Choice A rationale:

The nurse should prioritize providing information about alternate birth control methods to the client who is uncertain about undergoing a tubal ligation. This approach aligns with the principle of informed consent and patient autonomy. By presenting different options, the client can make a well-informed decision about their reproductive health. This ensures that the client's choice is based on a comprehensive understanding of all available alternatives.

Choice B rationale:

While involving the client's partner in the decision-making process can be important, the primary responsibility of decision-making lies with the client. Therefore, asking if the client has discussed the decision with their partner (Choice B) may not directly address the client's uncertainty and need for information about alternative birth control methods.

Choice C rationale:

Emphasizing the benefits of having the procedure (Choice C) might not be appropriate if the client is uncertain about whether it's the right choice for them. This approach may come across as biased and not respectful of the client's ambivalence. Providing unbiased information about all options is a more balanced approach.

Choice D rationale:

Discussing the client's feelings about the procedure (Choice D) is essential but should be done in conjunction with providing information about alternate birth control methods. Addressing the client's emotions without offering alternatives may not fully support the client's decision-making process.