A case manager is performing a home visit for a client following a stroke.
The client's partner is providing care in the home.
The client's partner states that she sometimes feels exhausted.
Which of the following referrals should the case manager recommend for the caregiver?

• A. Bowel sounds are hypoactive in all four quadrants, which is expected after an appendectomy due to anesthesia and decreased peristalsis. This is not a finding that needs to be reported to the provider.
• B. Oxygen saturation is 93% on room air, which is below the normal range of 95% to 100%. This could indicate impaired gas exchange, respiratory depression, or infection. This is a finding that needs to be reported to the provider.
• C. Nausea is a common feature of appendicitis and should go away with appendectomy. This finding should, therefore, be reported to the healthcare provider.
• D. Vomiting is also a common side effect of morphine and anesthesia, and can be managed with antiemetics and fluids. This is not a finding that needs to be reported to the provider unless it persists or interferes with oral intake.
• E. Pain level is 6 on a scale of 0 to 10.The client received morphine as prescribed at 1815, and the pain level is still significant. This isa finding that needs to be reported to the provider
• F. Heart rate is 110/min, which is above the normal range of 60 to 100/min. This could indicate pain, anxiety, dehydration, infection, or bleeding. This is a finding that needs to be reported to the provider.
• G. Incision characteristics are clean and dry, which is expected after an appendectomy. However, the nurse should monitor for signs of infection such as redness, swelling, warmth, drainage, or odor. This is a finding that needs to be reported to the provider if any signs of infection are present.
• H. Lungs sounds are clear on auscultation, which is expected after an appendectomy. However, the nurse should encourage deep breathing and coughing exercises to prevent atelectasis and pneumonia. This is a finding that needs to be reported to the provider if any abnormal lung sounds are heard such as crackles, wheezes, or diminished breath sounds.

Choice A rationale:

This statement implies that the nurse attempted the dressing change but was unsuccessful. However, the information about the dressing not being soiled is irrelevant to the incident report. The key issue is the omission of the prescribed procedure.

Choice B rationale:

This statement acknowledges the omission but lacks specificity. It does not state the nature of the omission or the potential consequences, making it less informative for future prevention strategies.

Choice C rationale:

This statement clearly and concisely states the situation, indicating that the prescribed dressing change was omitted. It provides essential information for understanding what happened, allowing for appropriate investigation and preventive measures.

Choice D rationale:

This statement confirms the completion of the incident report but does not provide details about the incident itself. Without specific information about the omission, this statement is insufficient for understanding the nature of the error and implementing preventive actions.