A nurse administers an incorrect dose of medication to a client. The nurse recognizes the error immediately and completes an incident report. Which of the following facts related to the incident should the nurse document in the client's medical record?

A. Assessing fluid intake every 24 hr is important for a postoperative client, but it is not the priority action. The nurse should monitor fluid intake and output more frequently, such as every 8 hr or every shift, to detect any imbalances or complications.

B. Ambulating three times a day is beneficial for a postoperative client, but it is not the priority action. The nurse should encourage early and frequent ambulation to promote circulation, prevent thromboembolism, and enhance bowel function, but only after ensuring that the client is stable and has adequate pain control.

C. Assisting with deep breathing and coughing is the priority action for a postoperative client who had abdominal surgery. The nurse should help the client perform these exercises every 1 to 2 hr to prevent atelectasis, pneumonia, and respiratory failure, which are common and serious complications after abdominal surgery.

D. Monitoring the incision site for findings of infection is important for a postoperative client, but it is not the priority action. The nurse should inspect the wound for signs of infection, such as redness, swelling, warmth, drainage, or odor, but this can be done during routine dressing changes or as needed.

Choice A reason:

Allow the client's partner to translate. While the partner may be well-intentioned, using a family member or friend as an ad-hoc interpreter can compromise the confidentiality of the information and may not accurately convey the client's medical concerns.

Choice B reason:

Have the client's child translate. Relying on a child to translate sensitive medical information is inappropriate, as it may burden the child and may lead to potential misunderstandings or omissions in communication.

Choice C reason:

Ask a nursing student who speaks the same language as the client to translate. Although a nursing student who speaks the same language as the client may be able to assist, using a professional interpreter is the preferred option. Professional interpreters have specific training in medical terminology and communication, ensuring the most accurate and effective exchange of information.

Choice D reason:

Using a professional interpreter is essential in situations where the healthcare provider and the client do not speak the same language. It ensures accurate communication, maintains confidentiality, and prevents misunderstandings. In this scenario, the nurse should request an interpreter who is proficient in the client's language to assist with the admission process.