M36 Clinical Decision Making Exemplar Prioritizing Care

The nurse is prioritizing client care as​ low, medium, or high priority for the current assignment. Which client should the nurse identify as having a ​high-priority​ circumstance? (Select all that​ apply.) A.A client who is experiencing extreme bouts of diarrhea B.An extremely confused older client C.A client with emphysema and a pulse oximeter reading of 88 D.A client who is receiving warfarin​ (Coumadin) E.A client with congestive heart failure and shortness of breath

C,D,E Rationale: High-priority circumstances include clients with a risk for​ bleeding, such as a client receiving warfarin​ (Coumadin), clients with ineffective breathing​ patterns, and clients with impaired gas exchange. A confused client and a client with diarrhea would have​ medium-priority circumstances.

The home care nurse is planning the order of clients for the day. Which client should the nurse prioritize as needing to be seen first​? A.A newly diagnosed diabetic client who is administering morning insulin independently for the first time B.A client requiring indwelling catheter change due to leakage C.A client being seen poststroke for rehabilitation and education about poststroke care D.A client with daily dressing​ change, normally done at 0800 per client preference

A Rationale: A newly diagnosed client who is administering insulin independently for the first time creates a time constraint. The nurse would see this client first to ensure that the insulin is being administered properly. While client preferences are an important​ consideration, the time constraint of the insulin would be a higher priority. A client being seen poststroke for rehabilitation and education as well as a client with a leaking indwelling catheter would also be lower priorities when planning the order of clients for the day.

The nurse administered blood pressure medications to the wrong client. Upon realizing the​ error, the nurse notes that the last blood pressure assessment of the client who received the wrong medication was​ 82/50 mmHg. Which level of urgency would be required to address this​ situation? A.Critical B.Acute C.Nonacute D.Imminent death

A Rationale: In this​ situation, a blood pressure medication was administered to the wrong client who has low blood​ pressure, creating a critical situation to which the nurse needs to respond quickly since the​ client's condition could become life threatening. This would not be an acute or nonacute​ situation, as it is a​ medium-high priority. It is not likely that this error would result in death of the​ client, so the choice of imminent death would not be appropriate.

Which client should the nurse assess first after receiving the​ change-of-shift report? A.A client with heart failure who is complaining of shortness of breath B.A client with type 1 diabetes mellitus with blood glucose of 82​ mg/dL C.A client with a bowel obstruction who is complaining of nausea D.A client with hypertension with a blood pressure of​ 168/88 mmHg

A Rationale: Using the ABCs​ (airway, breathing, and​ circulation) as a​ guide, the nurse should first assess the client with shortness of breath. This would take priority over a client complaining of​ nausea, a client with an elevated​ (but not critically​ elevated) blood​ pressure, and a client with a normal blood glucose reading.

The nurse working in a community clinic is reviewing the clients to be seen for the day. Which client should require more time in the​ schedule? A.A​ 75-year-old with recent cognitive decline B.A​ 32-year-old with newly diagnosed diabetes who is returning for a blood glucose recheck C.A​ 50-year-old who is being seen for blood pressure recheck D.A​ 20-year-old who is being seen for evaluation of insulin pump management

A ​Rationale: An older client with cognitive issues may require more time than do other clients due to both developmental and cognitive issues. Blood pressure​ rechecks, insulin pump​ follow-up, and blood glucose rechecks of young and​ middle-aged adults would not necessarily require more time.

The nurse working on a busy medical-surgical unit is caring for five clients. As the nurse is preparing to administer routine medications to the assigned​ clients, she is informed that a new admission will be arriving to the unit shortly. Which type of situation challenges the​ nurse's time management and organizational​ skills? A.​Pop-up B.Pitfall C.Emergent D.Urgent

A ​Rationale: Events such as new admissions that are unexpected and require that nurses take time and attention away from their plan for the day are referred to as​ pop-ups. Pitfalls are unforeseen situations that harbor consequences for nurses and can result in client harm. Urgent and nonurgent events are methods of triaging and setting priorities for care.

Which action should the nurse take to best involve hospitalized clients in their care and avoid pitfalls related to not involving clients in their own​ care? A.Observing client behaviors for cues about preferences B.Orienting the client and family to the hospital facility and routines C.Asking the​ client's family about usual patterns of behavior D.Informing clients of the daily schedule of care

A ​Rationale: To avoid pitfalls related to not involving clients in their own​ care, the nurse should observe client behaviors for cues about preferences. Informing clients about the daily schedule of care and orienting clients and families to the hospital routine do not provide information about client preferences. While a family may be able to provide information concerning client​ preferences, it is best to ask or observe the client to determine preferences.

Which action by the nurse can help to avoid pitfalls that can result in client​ harm? (Select all that​ apply.) A.Following ethical care practices B.Prioritizing client care appropriately C.Incorporating client preferences as possible when prioritizing care D.Delegating care only when absolutely necessary E.Knowing client healthcare concerns

A,B,C,E Rationale: To avoid common pitfalls when providing​ care, the nurse should follow ethical care​ practices, know client healthcare​ concerns, prioritize care​ appropriately, and incorporate client preferences as possible when prioritizing client care. Appropriate delegation can be helpful to the nurse when prioritizing​ care, so it should not be avoided but used appropriately.

A homeless client presents to the emergency department​ (ED) complaining of severe chest pain. The client is well known to the​ ED, coming in frequently for various minor complaints. Which ethical principles should be most important for the nurse to​ consider? A.Nonmaleficence and beneficence B.Justice and fairness C.Accountability and responsibility D.Privacy and confidentiality

B Rationale: The principle of justice guides nurses in making decisions about setting priorities.​ Additionally, nurses must show fairness in treating individuals as equals. In this​ scenario, the nurse must treat the homeless client like any other client seeking care for chest pain.​ Accountability, responsibility,​ privacy, confidentiality,​ nonmaleficence, and beneficence are all important ethical considerations for the nurse but are not directly relevant to the situation.

The nurse in an emergency department​ (ED) shares with a fellow nurse​ that, due to the busy pace of the​ day, he has not even been able to go to the bathroom since he arrived for his shift 6 hours ago. Which response by the fellow nurse should best address this​ situation? A.Listening to the​ nurse's concerns and offering verbal encouragement to make it through the rest of the shift B.Offering to oversee the​ nurse's clients so that a​ 15-minute break can be taken C.Discussing better ways to prioritize and manage time with the nurse so that in the future he will be able to take needed breaks D.Encouraging the nurse to let the supervisor know so that appropriate actions can be taken

B ​Rationale: It is important that nurses take quick​ 15-minute breaks to​ refresh, reenergize, and take care of bodily​ functions, so the best response by the fellow nurse would be to cover for the nurse to allow this break to occur. Encouraging the nurse to let the supervisor​ know, listening to the​ nurse's concerns, and discussing better ways to manage time and prioritize would not provide the​ much-needed break for the nurse.

The medical-surgical nurse is planning the day immediately after receiving report. Which should be the primary nursing intervention when prioritizing​ care? A.Analyzing collected data B.Assessing client situations C.Ascertaining interventions D.Assigning staff to clients

B ​Rationale: The first step when prioritizing care is assessment. Assessment is the process of gathering information to make decisions. Assessment includes knowing individual​ clients' health statuses to prepare for anticipated or unanticipated changes. Ascertaining interventions would occur after the assessment. Analyzing collected data would occur after an assessment. Assigning staff to clients would occur after knowing the number and level of caregivers available to provide care.

A client is admitted to the emergency department with a rash on the trunk and extremities. The client reports difficulty​ breathing, chest​ tightness, and weakness. Respirations are 24​ breaths/min and​ even, pulse is 90​ beats/min and​ thready, and blood pressure is​ 96/70 mmHg. The client reports a recent history of a urinary tract infection and having been on sulfasalazine for the past 5 days. Which is the priority nursing assessment for this​ client? A.Peripheral edema B.Airway patency C.Gastrointestinal disturbances D.Urine discoloration

B ​Rationale: Using the ABCs​ (airway, breathing, and​ circulation) to establish priority nursing​ interventions, the nurse would first establish airway patency based on the​ client's symptoms of difficulty breathing. This would take priority over assessment for​ edema, urine​ discoloration, and gastrointestinal disturbances.

A client presents to the emergency department​ (ED) complaining of pain and burning on urination. The client also tells the triage nurse that she noted blood in the urine the past few times she​ urinated, so she thought she should come to the emergency department. In which category should the nurse classify the​ client's problem to prioritize care in relation to other clients in the​ ED? A.Urgent B.Emergent C.Nonurgent D.Immediate

C Rationale: Symptoms indicate that this client may be experiencing a urinary tract​ infection, which would be considered nonurgent since a delay in treatment would not result in a​ life-threatening situation. It would not meet the criteria for urgent or​ emergent/immediate.

The nurse caring for a client with diabetes mellitus receives a report from another nurse that the client is experiencing a hypoglycemic episode. The nurse immediately prepares to administer 50 mL of D50 IVP. Upon entering the​ room, the nurse notes that the client seems alert and does not have any current complaints and decides not to administer the D50. Which pitfall was avoided by the nurse in this​ situation? A.Incomplete assessment B.Poor time management C.Relying solely on​ another's assessment D.Failure to do periodic assessments

C ​Rationale: In this​ situation, the nurse prepared to administer D50 IVP based on the other​ nurse's assessment. Using this information to set priorities could have resulted in a negative client outcome. The potential pitfall in this situation was not created by an incomplete​ assessment, poor time​ management, or failure to do periodic assessments.

A new graduate nurse is having difficulty prioritizing care and leaving the shift in a timely manner. The nurse manager notes that the new nurse rarely delegates tasks to the unlicensed assistive personnel​ (UAP) since a recent incident in which the new nurse delegated an inappropriate task to a UAP. Which action by the nurse manager should best help to address this​ situation? A.Encouraging the nurse not to let the recent experience impact future actions B.Reminding the nurse that she will quickly burn out if she does not delegate some care to the UAP C.Reviewing state and facility guidelines concerning delegation with the nurse D.Having the UAP discuss with the nurse appropriate activities that he can do to assist the nurse with client care

C ​Rationale: To avoid pitfalls concerning delegation of​ activities, the nurse should be aware of state and facility guidelines.​ Thus, the best action of the nurse manager would be to discuss these guidelines with the new nurse. Encouraging the nurse not to let past experience guide future actions would not help the nurse to understand appropriate guidelines for delegation. Reminding the nurse that she will burn out quickly if she does not delegate tasks does not help the nurse learn to delegate tasks appropriately. Nurses should not rely solely on UAPs to indicate which tasks can appropriately be​ delegated; they should follow state and facility guidelines.

The nurse is providing care for several clients with neurologic dysfunction. Which client should be placed closest to the​ nurses' station? A.A preoperative​ 68-year-old client who was diagnosed with an astrocytoma B.A​ 72-year-old client who is 2 days postoperative for a carotid endarterectomy C.A newly admitted​ 65-year-old client who experienced an acute subdural hematoma D.An​ 80-year-old client with viral meningitis who was admitted 3 days ago

C ​Rationale: When prioritizing​ care, the nurse needs to consider all relevant factors. A newly admitted client with a recent subdural hematoma would be considered a high priority due to risk for​ seizures, stroke, brain​ herniation, and so forth and should be placed closest to the​ nurses' station. A client 3 days​ postmeningitis, a preoperative​ client, and a client who is 2 days postoperative for a carotid endarterectomy would have more stability and less priority than a newly admitted client with a subdural hematoma.

The nurse is organizing care for the day for the assigned clients. Which client should the nurse give highest prioritization to ensure appropriate medication​ administration? A.A client with diabetes requiring insulin coverage QID B.A client with unstable vital signs receiving multiple blood pressure medications C.A client receiving several intravenous​ antibiotics, each to be infused over 30-60 minutes D.A client who is receiving daily dialysis

C ​Rationale: When the nurse is caring for multiple​ clients, setting of priorities is determined by the significance of the interventions for the clients. In this​ situation, the client receiving several intravenous​ antibiotics, each of which need to be infused over a specific time​ frame, would need to be prioritized to ensure adequate medication administration. QID insulin​ coverage, regularly scheduled blood pressure​ medications, and daily scheduled dialysis would not have higher prioritization than would the client receiving multiple intravenous antibiotics that must be administered in the correct order over the appropriate time frame.

The nurse is assessing a​ client's peripheral circulation after cardiac catheterization. Which finding is the highest​ priority? A.The​ client's toes are warm and pink. B.The femoral site is soft and free of hematoma or bleeding. C.Pulses are palpable and bounding. D.The client is experiencing numbness in the toes.

D Rationale: After cardiac​ catheterization, a finding that the client is experiencing numbness may indicate a complication of the​ procedure, thus it would be the highest priority. Warm and pink​ toes, palpable, bounding​ pulses, and a femoral site free of hematoma and bleeding are all normal findings.

The nurse is planning the day on a general medical unit. Which activity should the nurse prioritize as​ "must do" and not advisable to be delegated to unlicensed assistive personnel​ (UAP)? A.Ambulating a stable client to the bathroom B.Assisting clients with hygienic care activities C.Collecting vital signs on assigned clients D.Health teaching for a client being discharged poststroke

D ​Rationale: "Must​ do" activities carry the highest priority for completion and should not be delegated. Health teaching and discharge teaching must be done by the nurse. Collecting vital​ signs, ambulating a stable client to the​ bathroom, and assisting clients with hygienic activities can all be safely delegated to unlicensed assistive personnel​ (UAPs).

The nurse prioritizes care for a client with diabetes mellitus using​ Maslow's hierarchy of needs. Which need is identified as the priority for this​ client? A.The nurse teaches the client proper home safety techniques to prevent diabetic wounds. B.The client attends classes to deal with body image after amputation of the right leg. C.The client joins the local American Diabetes Association support group. D.The nurse teaches the client how to properly change dressings on the​ right-leg amputation site.

D ​Rationale: When prioritizing care based on​ Maslow's hierarchy of​ needs, physiological needs will come before​ safety, social, and esteem needs. Caring for an amputation site is meeting a physiological need. Attending a class to deal with​ body-image issues addresses an esteem need. Teaching the client about safety techniques to prevent diabetic wounds addresses a safety need. Joining a support group meets an esteem need.