Engage PN: Managing Client Care
A charge nurse is teaching a group of nurses about protecting themselves from an abusive client. Which of the following statements by a nurse within the group demonstrates an understanding of the teaching?
"I should try to escape or put a barrier between myself and the client." The nurse should always try to escape a dangerous situation. If escape is not possible, creating a barrier where the client cannot reach them until help arrives is the next acceptable action.
A nurse is precepting a newly licensed nurse and suggests using the IDEAL method to structure the client's discharge planning. The client's caregiver is also in the room. Which of the following statements made by the newly licensed nurse demonstrates the correct the use of the IDEAL method?
"I will include the client and caregivers in the discharge discussion." "I" stands for "include" in this model. The nurse should include the client and caregivers to review the discharge instructions. Research shows including caregivers in the discharge instructions with the client leads to a safer transition.
A nurse is teaching the SMART goal method to a client who has diabetes mellitus and is setting nutrition and weight loss goals. Which of the following client statements should indicate to the nurse an understanding the teaching?
"I will reduce my sugar intake by 10 grams each week for one month until I reach the desired level." This response indicates the client understands and is using the SMART goal method: creating goals that are specific (S), measurable (M), attainable (A), realistic (R), and timely (T).
A nurse is caring for a client who is being transferred to another unit, but the receiving nurse is unavailable to take report. Which of the following concepts is being violated that could place the client at risk?
Continuity of care The nurse should understand that continuity of care can cause a safety risk of a client when there are numerous hand-off reports completed during a transfer to another unit. The nurse should wait until the other nurse is available for report.
A newly licensed nurse is reviewing the client assignments for a shift and determining tasks to complete. Which of the following is a time management strategy the nurse should use?
Make a list and prioritize a plan. Managing multiple clients can be difficult for a new nurse. Making a list of all tasks to accomplish and then prioritizing a plan can help the nurse stay organized and efficient.
A nurse is giving change-of-shift report to an oncoming nurse using SBAR reporting. Which of the following entries by the nurse demonstrates the correct use of SBAR?
The client in room 1 has been experiencing breakthrough pain following an exploratory surgery yesterday. Vital signs are stable. Recommend calling the provider for a breakthrough dose if pain continues. The nurse is providing relevant and needed information for SBAR reporting: situation, background, assessment, and recommendation.
A nurse is speaking with a client who is non-compliant in performing a daily blood glucose testing regimen. Which of the following responses should the nurse make?
What is preventing your consistency with your daily blood glucose checks?" The nurse is using an open-ended question to encourage the client to talk more about what is hindering them from the process for daily blood glucose testing.
A charge nurse is teaching a newly licensed nurse about the concept of team nursing. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
"Nurses will pair together to care for an assigned group of clients." Team nursing is the concept of nursing that pairs two or more nurses together to provide care for a group of clients. Team nursing provides support for novice nurses and others that are not as skilled in performing more complex tasks. A positive outcome of team nursing is the team works together. No one is expected to perform tasks that they are uncomfortable with or not competent to perform.
A charge nurse is reviewing client acuities and tasks to make the nursing staff's daily assignments. When using the Five Rights of Delegation, which of the following should the charge nurse use to ensure client safety?
Right task The charge nurse should delegate an assignment or task that is safe for a health care worker to carry out. Safety includes right training, competency, or within the health care worker's scope of practice.