Exemplar 36.C: Prioritizing Care

The nurse is preparing to provide care to a group of clients. On which specific areas should the nurse focus in order to prioritize the clients' care needs? Select all that apply. A) Asking if any clients have complex issues B) Noting number of licensed staff assigned for the shift C) Noting time when the attending physicians make rounds D) Identifying clients with specific medication times E) Noting which clients have particular safety needs

A) Asking if any clients have complex issues D) Identifying clients with specific medication times E) Noting which clients have particular safety needs Setting priorities for nursing care always begins with assessment. Assessment includes making observations and asking questions to gather information necessary to make decisions. Helpful assessment data include knowing which clients have complex care issues, if any clients have particular medication times, and if any clients have safety issues that should be addressed. The number of licensed staff is not as important as knowing the number of unlicensed assistive personnel to whom the nurse can delegate client care activities. The time when attending physicians make rounds is not usually part of the criteria when prioritizing client care needs.

After receiving the morning report, the nurse prioritizes care needed by several clients. Which factors should the nurse keep in mind when creating this priority list? Select all that apply. A) Client condition B) Safety C) Time available D) Client preferences E) Nurse preferences

A) Client condition B) Safety C) Time available D) Client preferences Prioritization means more than just making decisions about which interventions to do first, second, or third. Factors that influence prioritization include client condition, safety factors, available time, and client preferences. A change in client status may very well require reevaluating priorities and changing the planned order of interventions. Nurses can be fair in their allocation of time, attention, and skills to ensure client safety. Time priorities are determined by the urgency of completing the interventions for the clients. The nurse should strive to honor the client's wishes as much as possible and complete nursing interventions as needed. The nurse needs to complete priority tasks whether or not the task is enjoyable, so nurse preferences are often set aside when creating a priority list of care needed by clients.

The nurse manager is concerned that a staff nurse is having difficulty prioritizing client care needs. Which did the manager observe the nurse perform that caused these concerns? Select all that apply. A) Relying on another nurse's assessment B) Reviewing the medication administration record C) Not completing an assessment D) Doing easiest tasks first E) Asking unlicensed assistive personnel to perform complicated care

A) Relying on another nurse's assessment C) Not completing an assessment D) Doing easiest tasks first E) Asking unlicensed assistive personnel to perform complicated care Obtaining assessment data from another nurse can provide insight and give a picture of how a client has been during the previous shift; however, using only this information to set priorities may negatively impact client outcomes. Failing to complete an assessment can cause the nurse to miss important and necessary information when setting priorities. Completing easy tasks before doing important, necessary tasks does not make good, professional common sense. Inappropriate delegation may result in the nurse having to do an intervention over or may even result in harm to the client. Reviewing the medication administration record does not negatively impact prioritization.

The nurse is prioritizing care for a client with several problems. List the order in which the nurse should address the client's needs. A) Bleeding through nasogastric tube B) Audible wheezes C) Not understanding how to complete the menu D) Requesting medication for arthritis pain E) Dyspnea F) Asking questions about teaching provided the other day

Answer: B, E, A, D, F, C The nurse's priority should follow the ABCs, or airway, breathing, and circulation. - Audible wheezes could indicate an obstruction and should be attended to first. - Dyspnea indicates a problem with breathing and should be addressed next. -Bleeding could impact circulation and should be addressed third. - Pain control should be addressed fourth. - Reinforcement of teaching can occur fifth, and helping with menu completion can occur last.

The nurse is prioritizing care activities that are to be completed for a group of clients. From highest to lowest priority, list the order in which the nurse should complete the listed activities. A) Measure blood pressure before administering antihypertensive medication. B) Request dietary consult for gluten-free diet. C) Remove an intravenous access device infusing chemotherapy. D) Change a dressing on an arm wound. E) Call a family member to bring in shoes. F) Ambulate to the bathroom using a walker.

Answer: C, A, D, F, B, E The highest-priority action would be to remove an intravenous access device infusing chemotherapy because this could lead to significant tissue damage. Measuring blood pressure before administering antihypertensive medication is the next priority because this could be a timed intervention. Changing a dressing on an arm wound can occur anytime throughout the shift. Ambulating using a walker to the bathroom can be delegated to unlicensed assistive personnel. Requesting a dietary consult for gluten-free diet can also be done at any time and does not have a specific degree of urgency. Contacting family to bring in shoes can be completed at the end of the shift or delayed to the next shift.

The nurse is prioritizing care for a client based on nursing diagnoses. If following Maslow's hierarchy of needs, list the order in which the nurse should provide care to the client. A) Fatigue B) Anxiety C) Alteration in Perfusion D) Self-Care Deficit E) Deficient Knowledge F) Diarrhea

Answer: C, F, D, B, A, E High-priority nursing diagnoses should be addressed first. This means that Alteration in Perfusion would be the first priority. Medium-priority diagnoses should be addressed next, in order of the impact on physiologic processes. Diarrhea would be a priority over Self-Care Deficit; however, Self-Care Deficit would be a priority over Anxiety. Low-priority diagnoses would be addressed last, again in order of physiologic impact. Fatigue would be a priority over Deficient Knowledge.

The nurse is prioritizing care needed for a group of clients according to urgency. Which care should the nurse identify as being medium priority? Select all that apply. A) Instructing on changing ostomy appliance B) Performing passive range of motion every 4 hours C) Removing splints and providing complete skin care every 2 hours D) Administering 2 units of fresh frozen plasma E) Performing endotracheal suction

B) Performing passive range of motion every 4 hours C) Removing splints and providing complete skin care every 2 hours Medium-priority interventions are those that would not cause a life-threatening situation if performed later throughout the shift. These interventions include passive range of motion exercises and removing splints for skin care. Instructing on ostomy appliance changes is a low-priority intervention. Administering fresh frozen plasma and endotracheal suctioning would be considered critical interventions because if these interventions were not performed, the client's health status could quickly deteriorate.

What is one of the primary reasons that it is important for nurses to prioritize care? A) Nurses need to plan how to accomplish all activities within one shift. B) Nurses can accomplish more if they perform the easiest or fastest interventions first. C) Nurses should perform interventions related to client preferences early in the shift. D) Nurses only have a limited amount of time to perform nursing interventions.

D) Nurses only have a limited amount of time to perform nursing interventions. Nurses only have a limited amount of time to perform nursing interventions. By prioritizing care, nurses can ensure that high-priority interventions are completed first, followed by medium-priority and then low-priority interventions as time allows. It will likely not be possible for a nurse to plan how to accomplish all activities within one shift. Nurses often accomplish less and are more stressed if they perform the easiest or fastest interventions first. Nurses should consider client preferences for all interventions regardless of the time the intervention is completed.

The nurse is preparing to triage victims of a train derailment who are being transported to the emergency department. Which victims would need immediate care? Select all that apply. A) Holding broken arm, sitting in a chair B) Respiratory rate of 8 and irregular C) Bleeding from fractured limb with a blood pressure of 78/40 mmHg D) Bleeding from superficial facial wounds and talking to family E) Walking with a slight limp, asking for something to drink

B) Respiratory rate of 8 and irregular C) Bleeding from fractured limb with a blood pressure of 78/40 mmHg Emergent or immediate care is needed for life-threatening issues that require prompt treatment and care. Stabilization of the client's condition is critical. A respiratory rate of 8 and a blood pressure of 78/40 mmHg would be emergent. Urgent or delayed care is for serious health conditions in which a delay of treatment and care would not result in life-threatening situations. Holding a broken arm sitting in a chair and bleeding from superficial facial wounds while talking with family would be urgent. Nonurgent or minor issues do not require prompt care. Many of these clients can ambulate and are stable in their conditions. The client walking with a limp and asking for something to drink would be nonurgent.