During change-of-shift report, a nurse discovers they overlooked a prescription for a type and cross-match of a client who is to have surgery the next day. Which of the following actions should the nurse take first?

Obtain the client's type and cross-match.

Inform the provider of the delay in obtaining the type and cross-match.

Document the incident in the client's medical record.

Prepare an incident report for risk management.

Answer and Explanation

The Correct Answer is A

A.   Obtaining the client's type and cross-match is the first action the nurse should take because it ensures that the client will have compatible blood available for transfusion if needed during surgery.
B.   This is important but should only be done after obtaining the client’s type and cross-match.
C.   This should be done after obtaining the client’s type and cross-match.

D. While an incident report may be necessary, the immediate priority is to address the oversight and ensure patient safety.

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Correct Answer is B

Explanation

A. While it may be necessary to notify risk management eventually, the immediate priority is to ensure the client's safety and well-being.
B. The nurse should promptly assess the client for signs and symptoms of an allergic reaction and initiate appropriate interventions as necessary.
C. Documentation of the medication error and allergic reaction should be completed after ensuring the client's immediate needs are addressed.
D. Administering an antidote may be appropriate in certain situations, but the nurse should first assess the client's condition and follow established protocols for managing allergic reactions.

A. Pupils that are 8 to 9 mm in diameter B. Eyelids that blink involuntarily 30 to 35 times per minute C. Eyelashes that curl slightly outward. D. Corneas with an opaque appearance

Correct Answer is C

Explanation

A. Pupil size can vary but is typically around 3 to 5 mm in diameter under normal conditions.
B. The normal rate of involuntary blinking (spontaneous blinking) is approximately 15 to 20 times per minute.
C. Outwardly curling eyelashes are a normal anatomical variation and do not indicate any pathology.

D. Corneas should appear clear and transparent under normal conditions. Opacity of the cornea can indicate various eye disorders.

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During change-of-shift report, a nurse discovers they overlooked a prescription for a type and cross-match of a client who is to have surgery the next day. Which of the following actions should the nurse take first?

Nursing Test Bank

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