When performing a focused gastrointestinal system assessment, the practical nurse (PN) asks a male client when his last bowel movement occurred. The client answers, "Three days ago.”. Which action should the PN implement first?

Correct Answer: D. Report the findings to the charge nurse.

Choice A rationale:

Monitoring the client's temperature hourly may be indicated if the client's condition deteriorates or if there are specific concerns about fever. However, the temperature of 99.8°F (37.66°C) is not significantly elevated and may not be the primary concern in this situation.

Choice B rationale:

Offering the client fluids frequently is a good nursing practice, but it is not the most important intervention in this case. The client's nonproductive cough and increased confusion need to be addressed and reported first.

Choice C rationale:

Providing care to moisten oral mucosa is important for maintaining oral health and preventing dryness and discomfort. However, it may not directly address the client's current symptoms of cough and confusion.

Choice D rationale:

Reporting the findings to the charge nurse is the most crucial intervention. The client's nonproductive cough and increased confusion may be indicative of an underlying issue, such as a respiratory infection or a change in neurological status. The charge nurse can initiate further assessments, notify the healthcare provider, and implement appropriate interventions to address the client's condition promptly. Timely reporting and communication are essential to ensure the client receives appropriate care.

The correct answer is choiceB. Verify completion of all new prescriptions. This task is crucial to ensure patient safety and proper medication administration.

Choice A rationale:

Clean up and organize the nurses’ workstation: While maintaining an organized workstation is important for efficiency and reducing stress, it is not the highest priority task. Patient safety and care tasks take precedence over organizational tasks.

Choice B rationale:

Verify completion of all new prescriptions: This is the highest priority because verifying new prescriptions ensures that patients receive the correct medications as prescribed by their healthcare providers.This step is critical to prevent medication errors, which can have serious or even fatal consequences. Ensuring the accuracy of medication orders directly impacts patient safety and care quality.

Choice C rationale:

Calculate and record intake and output totals: Monitoring and recording intake and output is important for assessing a patient’s fluid balance and overall health status. However, this task can be delegated to another team member and does not take precedence over verifying medication orders, which is more time-sensitive and directly related to patient safety.

Choice D rationale:

Write a narrative shift summary for each client: Documenting a shift summary is essential for continuity of care and communication between healthcare providers. However, this task can be completed after ensuring that all critical patient care tasks, such as verifying new prescriptions, are addressed first.