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 C

Explanation

A. While educating the client about the benefits of surgery is important, it is not appropriate to dismiss the client's concerns in this situation.

B. It is important to respect the client's autonomy and decision-making process. If the client expresses a desire to reconsider the surgery, their wishes should be respected.
C. The nurse should respect the client's decision and communicate their wishes to the surgical team for further discussion and decision-making.
D. While reassurance is important, it should be provided in a way that acknowledges and respects the client's concerns and decisions.

A. Notify the facility's risk management team. B. Assess the client for a change in condition. C. Place an incident report in the client's electronic medical record. D. Administer an antidote before notifying the provider.

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.

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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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