A 15-year-old adolescent male with a mild mental disability is hospitalized for minor surgery and tells the practical nurse (PN), "Wow! You have big breasts."

Which response is best for the PN to provide?

The correct answer is choiceB. Verify completion of all new prescriptions. This task is crucial to ensure patient safety and proper medication administration.

Choice A rationale:

Clean up and organize the nurses’ workstation: While maintaining an organized workstation is important for efficiency and reducing stress, it is not the highest priority task. Patient safety and care tasks take precedence over organizational tasks.

Choice B rationale:

Verify completion of all new prescriptions: This is the highest priority because verifying new prescriptions ensures that patients receive the correct medications as prescribed by their healthcare providers.This step is critical to prevent medication errors, which can have serious or even fatal consequences. Ensuring the accuracy of medication orders directly impacts patient safety and care quality.

Choice C rationale:

Calculate and record intake and output totals: Monitoring and recording intake and output is important for assessing a patient’s fluid balance and overall health status. However, this task can be delegated to another team member and does not take precedence over verifying medication orders, which is more time-sensitive and directly related to patient safety.

Choice D rationale:

Write a narrative shift summary for each client: Documenting a shift summary is essential for continuity of care and communication between healthcare providers. However, this task can be completed after ensuring that all critical patient care tasks, such as verifying new prescriptions, are addressed first.

This is the finding that the PN should report to the charge nurse because it indicates a possible complication of Guillain-Barre syndrome, which is autonomic dysfunction. This can affect the cardiac, respiratory, and gastrointestinal systems and cause life-threatening problems such as arrhythmias, hypotension, or respiratory failure. The PN should monitor the client's vital signs closely and report any abnormal changes.

B. Profuse diaphoresis is not a priority finding and may be related to other factors such as fever, anxiety, or medication side effects.

C. Lower leg weakness is an expected finding in Guillain-Barre syndrome and does not need to be reported unless it progresses rapidly or affects the respiratory muscles.

D. Full facial flushing is not a priority finding and may be related to other factors such as vasodilation, inflammation, or medication side effects.