Safe, Effective Care Environment
20. Which finding should a nurse report immediately to a physician?
Safe, Effective Care Environment
20. Which finding should a nurse report immediately to a physician?
. After 2 days of IV penicillin, client has developed a rash around neck and face.
. Client has only eaten 20% of the meals for 2 days.
. Client who has a pulse of 100 and irregular; who was previously 80 and regular.
. No bowel movement for 4 days, and a firm abdomen.
Test-Taking Tip
Consider which situation requires the nurse to collaborate with the physician to meet the client's needs.
Content Area: Adult Health, Triage; Integrated Process: Communication and Documentation; Cognitive Level: Analysis; Client Need/Subneed: Safe and Effective Care Environment/Management of Care/Collaboration with Interdisciplinary Team
Safe, Effective Care Environment
.
Answer 1 is incorrect because, if a rash develops after several days of therapy, it is not an emergency situation. The rash may or may not be related to the drug. Answer 2 is incorrect because there are independent nursing actions that need to be considered before contacting the physician. Answer 3 is correct because a change in cardiac status is a priority and potentially life threatening, which requires the nurse to collaborate with the physician on the appropriate action. Answer 4 is incorrect because there are additional actions by the nurse that can be done before contacting the physician—checking for bowel sounds, a review of the client's dietary intake, activity status, and checking for impaction.