During change-of-shift report, a nurse discovers they overlooked a prescription for a type and cross-match of a client who is to have surgery the next day. Which of the following actions should the nurse take first?

Obtain the client's type and cross-match.

Inform the provider of the delay in obtaining the type and cross-match.

Document the incident in the client's medical record.

Prepare an incident report for risk management.

Answer and Explanation

The Correct Answer is A

A.   Obtaining the client's type and cross-match is the first action the nurse should take because it ensures that the client will have compatible blood available for transfusion if needed during surgery.
B.   This is important but should only be done after obtaining the client’s type and cross-match.
C.   This should be done after obtaining the client’s type and cross-match.

D. While an incident report may be necessary, the immediate priority is to address the oversight and ensure patient safety.

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Correct Answer is A

Explanation

A. This action prevents recontamination of the hands after handwashing, which is an essential component of maintaining medical asepsis.
B. It is recommended to allow alcohol-based hand rub to dry completely before engaging in patient care to ensure effectiveness.

C. While handwashing with soap and water is appropriate, cold water may not be as effective as warm water for removing contaminants.
D. Alcohol-based hand rubs are not sufficient for cleaning visibly soiled hands; soap and water are required in such cases.

A. The client's pupils constrict in response to light. B. The client's tongue is in a midline position: C. The client has a symmetrical smile. D. The client turns their head against resistance.

Correct Answer is C

Explanation

A. This response is associated with cranial nerve II, the optic nerve.

B. Tongue position is associated with cranial nerve XII, the hypoglossal nerve.

C. A symmetrical smile is indicative of cranial nerve VII, the facial nerve.

D. This action is associated with cranial nerve XI, the accessory nerve.

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During change-of-shift report, a nurse discovers they overlooked a prescription for a type and cross-match of a client who is to have surgery the next day. Which of the following actions should the nurse take first?

Nursing Test Bank

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Correct Answer is A

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Correct Answer is C

Explanation

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