A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery.
The client’s BP was 126/72 mm Hg 15 min ago. The nurse now finds that the client’s BP is 176/96 mm Hg. Which of the following actions should the nurse take?

The correct answer is choice C, D, and E.

Choice A rationale:A client being unable to afford physical therapy is a financial issue, not an incident that affects patient safety or care quality. This situation should be addressed through social services or financial counseling, not an incident report.

Choice B rationale:A client being dissatisfied with meal temperature is a service quality issue, not a safety incident. This should be reported to the dietary department or patient services for resolution, not through an incident report.

Choice C rationale:A client’s visitor becoming dizzy and fainting in the client’s room is an incident that affects the safety of the visitor. An incident report should be completed to document the event, the visitor’s condition, and any actions taken to provide care or prevent future occurrences.

Choice D rationale:A client receiving burns from a heating pad is a safety incident that directly affects the client’s well-being. An incident report should be completed to document the injury, the circumstances leading to the burn, and any immediate care provided.

Choice E rationale:A client becoming disoriented and falling out of bed is a significant safety incident. An incident report should be completed to document the fall, the client’s condition, and any interventions implemented to prevent future falls.

The correct answer is choice B. Palliative care is a type of care that improves the quality of life of patients and their families who are facing problems associated with life-threatening illness.

It prevents and relieves suffering through the early identification, correct assessment and treatment of pain and other problems, whether physical, psychosocial or spiritual.

Palliative care also provides emotional support to the patients and their families during the illness.

Therefore, choice B indicates an understanding of the teaching.

Choice A is wrong because it contradicts the goal of palliative care to address the spiritual needs of the patients and their families.

Spiritual advisors can help patients cope with their illness and find meaning and purpose in their situation.

Choice C is wrong because it denies the patient the opportunity to express their feelings and concerns about their illness.

Palliative care involves open and honest communication between the patients, their families and the health care team.

Discussing the illness can help patients make informed decisions about their care and prepare for the end of life.

Choice D is wrong because it goes against the principle of palliative care to respect the patient’s wishes and preferences regarding their treatment.

Resuscitation is a procedure that attempts to revive someone from apparent death or unconsciousness.

Some patients may not want resuscitation if they have a terminal illness or a poor quality of life.

They may have an advance directive or a living will that states their preferences for end-of-life care.