165. A nurse is collecting a specimen for an aerobic culture from a client who has a draining pressure injury. Identify the sequence of actions the nurse should follow. (Move the Steps into the box on the right. placing them in the order of performance. use all the steps.)

A. Fill out an incident report: While documentation is essential for quality improvement and accountability, it is not the immediate priority. The client’s safety must be addressed before any administrative action is taken.
B. Report the incident to the nurse manager: Notifying the manager is an important step in the reporting chain, but it should occur after ensuring the client is stable and receiving appropriate clinical care.
C. Notify the provider: The provider must be informed to assess for possible interventions or antidotes, but the nurse should first collect the client’s current clinical status to report meaningful information.
D. Measure the client's vital signs: Assessing the client’s condition is the first priority after a medication error. Vital signs provide critical information on the client’s immediate response and help guide the next steps in managing the error.

Rationale for Correct Choices:

• Endometritis: The client has systemic signs (feeling unwell, low-grade fever), elevated WBC count, and local uterine findings indicating infection. Endometritis is a common complication postpartum, especially after cesarean birth with membrane rupture exceeding 24 hours.
• Uterus and lochia assessment: The presence of a boggy, tender uterus and foul-smelling, dark brown lochia are classic signs of endometritis. These findings, in the setting of cesarean delivery and prolonged rupture of membranes, point to uterine infection as the primary concern.

Rationale for Incorrect Choices:

• Pneumonia: The client lacks hallmark signs of pneumonia, such as productive cough, abnormal sputum, or abnormal chest auscultation like crackles or wheezing. Normal respiratory rate and oxygenation further reduce the likelihood of a lower respiratory tract infection.
• Mastitis: Typically presents with unilateral breast pain, erythema, warmth, and systemic symptoms like high fever and malaise. The client’s symptoms are more consistent with engorgement, making mastitis an unlikely cause.
• Lung sounds: While lung sounds are diminished at the bases, they are otherwise clear, and the client has normal respiratory rate and oxygen saturation. These findings do not support a diagnosis of pneumonia and may simply reflect postoperative atelectasis or limited mobility.
• Breast and nipple changes: Breast fullness and nipple discomfort are expected during lactation and suggest engorgement rather than mastitis. There is no redness, localized heat, or severe pain reported.