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.
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Related Questions
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.
Correct Answer is D
Explanation
A. Although this client may have physical limitations, they are still engaging in social activities by going to the gym, indicating less likelihood of social isolation.
B. This client has regular social interactions with family members, suggesting they are not socially isolated.
C. Regular social gatherings with friends indicate social engagement and are not indicative of social isolation.
D. Restricting activities outside the home to only essential tasks like getting the mail due to pain or other reasons can indicate social isolation and limited social interactions.
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