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.