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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A respiratory rate of 7/min is below the normal range and may indicate opioid- induced respiratory depression, which is a life-threatening complication requiring immediate intervention.
B. While important, a distended bladder does not pose an immediate threat to the client's life compared to respiratory depression.
C. Constipation is a common side effect of opioid medications but does not require immediate intervention unless accompanied by severe symptoms such as fecal impaction or bowel obstruction.
D. Pain management is important, but respiratory depression takes priority as it can lead to respiratory arrest and death.
Correct Answer is C
Explanation
A. While this technique can sometimes be helpful, it's not the first-line intervention for postoperative urinary retention. Encouraging fluids is a more fundamental step.
B. Lying supine may make it more difficult for the client to void. Sitting upright or ambulating to the bathroom may be more effective.
C. Encouraging fluids helps maintain adequate urine output, which is essential for preventing urinary retention after surgery. Dehydration can worsen the difficulty voiding.
D. Catheterization should be considered only after other interventions to promote voiding have been attempted and failed, as it carries the risk of infection and discomfort.
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