A nurse is teaching a newly licensed nurse about palliative care.
Which of the following information should the nurse include?

Choice A rationale:

Material safety data sheets (MSDS) primarily contain information related to hazardous chemicals and substances used in healthcare settings. While MSDS can be valuable for safety purposes, they do not provide comprehensive information on specimen collection protocols. Therefore, MSDS is not the most appropriate source for revising the specimen collection protocol.

Choice B rationale:

Client medical records are essential for individual patient care and documentation. However, they do not contain the information needed to revise the protocol for specimen collection on the unit. Medical records are specific to individual patient histories, diagnoses, and treatments, and do not address broader unit-wide protocols.

Choice C rationale:

Facility policy and procedures are the most appropriate source for retrieving information to revise the protocol for specimen collection on the unit. These policies and procedures are specifically designed to guide healthcare providers in delivering safe and effective care within the facility. They encompass standardized protocols for various clinical procedures, including specimen collection, making them the ideal source for the nurse's research.

Choice D rationale:

Evidence-based practice (EBP) involves using the best available research evidence, clinical expertise, and patient values to guide healthcare decisions. While EBP is crucial in healthcare, it is not the primary source for revising unit-specific protocols. EBP provides a broader framework for making clinical decisions but may not cover the specific policies and procedures unique to the facility.

The correct answer is to select the following three findings that require immediate follow-up:C. Urticaria,D. Blood pressure at 1630, andE. Report of dysphagia.

Choice A rationale:

“Breath sounds at 1600.” The breath sounds at 1600 were clear and present throughout, which is a normal finding and does not require immediate follow-up.

Choice B rationale:

“Temperature.” The temperature readings at both 1600 and 1630 are slightly elevated but not critically high. This does not require immediate follow-up compared to the other findings.

Choice C rationale:

“Urticaria.” The presence of urticaria (hives) indicates an allergic reaction, which can potentially escalate to a more severe reaction such as anaphylaxis.Immediate follow-up is necessary to prevent further complications.

Choice D rationale:

“Blood pressure at 1630.” The blood pressure at 1630 is significantly lower (78/52 mm Hg) compared to the earlier reading (110/58 mm Hg).This hypotension could indicate a serious reaction to the medication or another underlying issue that requires prompt attention.

Choice E rationale:

“Report of dysphagia.” The client’s report of difficulty swallowing and feeling a lump in their throat is concerning for a potential airway obstruction or severe allergic reaction, such as anaphylaxis.This symptom requires immediate follow-up to ensure the client’s airway remains open and to provide necessary interventions.