A nurse in the emergency department is caring for a 16-year-old client who reports abdominal pain and is accompanied by an adult neighbor. The provider diagnoses a ruptured appendix and states that the client requires an emergency appendectomy. Which of the following actions should the nurse take?

Choice A reason: This is not the correct choice because training LPNs to reinforce teaching with clients using a standardized teaching plan is a possible solution, but not the first step. The nurse manager should first identify the root cause of the problem before implementing any interventions.

Choice B reason: This is not the correct choice because including documentation of client education as part of unit nurses' annual performance evaluation is a way to monitor and evaluate the staff's performance, but not a way to improve it. The nurse manager should first address the barriers and challenges that prevent the staff from documenting client education effectively.

Choice C reason: This is the correct choice because determining factors that interfere with the documentation of client education is the first step in the quality improvement process. The nurse manager should use data analysis, staff feedback, and observation to find out the reasons for the low documentation results, such as lack of time, knowledge, skills, or resources.

Choice D reason: This is not the correct choice because offering incentives for the staff once the unit's results are back in adherence with the benchmark is a way to motivate and reward the staff, but not a way to solve the problem. The nurse manager should first implement evidence-based strategies to improve the documentation of client education, such as providing education, feedback, and tools.

The correct answer is: d.

Choice A reason: An allergy to penicillin requiring an alternative antibiotic to be prescribed is a common and expected variation in care. Allergies are patient-specific factors that must be accommodated within the care pathway. The need for an alternative antibiotic does not typically constitute a variance that requires reporting, as adjustments for allergies are part of personalized care planning.

Choice B reason: Initiating antibiotic therapy 2 hours after implementation of the care pathway may not require a variance report if it falls within the acceptable time frame for antibiotic administration. The timing of antibiotic therapy can be critical, but slight deviations are often accounted for within the care pathway guidelines. However, if the care pathway specifies a narrower time frame for initiation, then this could be a reportable variance.

Choice C reason: Changing the route of antibiotic therapy from IV to PO (oral) is a clinical decision that may be based on the patient's condition, progress, and ability to tolerate oral medications. This switch is a part of antimicrobial stewardship and is often encouraged when clinically appropriate to reduce IV line use and potential complications. It is a standard practice and does not typically require a variance report unless the change contradicts a specific protocol in the care pathway.

Choice D reason: Obtaining a blood culture after the initiation of antibiotic therapy is a significant variance from the standard care pathway. Blood cultures should be obtained before starting antibiotics to accurately identify the causative organisms and their antibiotic sensitivities. Starting antibiotics before obtaining blood cultures can reduce the likelihood of growing the bacteria in the culture, potentially leading to misdiagnosis and inappropriate treatment. This is a deviation from the standard of care that requires a variance report.