Saunders Review: Prioritizing Client Care: Leadership, Delegation, and Emergency Response Planning
The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client? 1. A client complaining of muscle aches, a headache, and history of seizures 2. A client who twisted her ankle when rollerblading and is requesting medication for pain 3. A client with a minor laceration on the index finger sustained while cutting an eggplant 4. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce
. Answer: 4 Rationale: In an emergency department, triage involves brief client assessment to classify clients according to their need for care and includes establishing priorities of care. The type of illness or injury, the severity of the problem, and the resources available govern the process. Clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, and acute neurological deficits and those who have sustained chemical splashes to the eyes are classified as emergent and are the highest priority. Clients with conditions such as a simple fracture, asthma without respiratory distress, fever, hypertension, abdominal pain, or a renal stone have urgent needs and are classified as a second priority. Clients with conditions such as a minor laceration, sprain, or cold symptoms are classified as nonurgent and are a third priority.
The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? 1. A postoperative client preparing for discharge with a new medication 2. A client requiring daily dressing changes of a recent surgical incision 3. A client scheduled for a chest x-ray after insertion of a nasogastric tube 4. A client with asthma who requested a breathing treatment during the previous shift
29. Answer: 4 Rationale: Airway is always the highest priority, and the nurse would attend to the client with asthma who requested a breathing treatment during the previous shift. This could indicate that the client was experiencing difficulty breathing. The clients described in options 1, 2, and 3 have needs that would be identified as intermediate priorities.
The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment? Select all that apply. 1. The acuity level of the clients 2. Specific requests from the staff 3. The clustering of the rooms on the unit 4. The number of anticipated client discharges 5. Client needs and workers' needs and abilities
Answer: 1, 5 Rationale: There are guidelines that the nurse should use when delegating and planning assignments. These include the following: ensure client safety; be aware of individual variations in work abilities; determine which tasks can be delegated and to whom; match the task to the delegatee on the basis of the nurse practice act and appropriate position descriptions; provide directions that are clear, concise, accurate, and complete; validate the delegatee's understanding of the directions; communicate a feeling of confidence to the delegatee and provide feedback promptly after the task is performed; and maintain continuity of care as much as possible when assigning client care. Staff requests, convenience as in clustering client rooms, and anticipated changes in unit census are not specific guidelines to use when delegating and planning assignments.
The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion? Select all that apply 1. Open doors to client rooms. 2. Move beds away from windows. 3. Close window shades and curtains. 4. Place blankets over clients who are confined to bed. 5. Relocate ambulatory clients from the hallways back into their rooms.
Answer: 2, 3, 4 Rationale: In this weather event, the appropriate nursing actions focus on protecting clients from flying debris or glass. The nurse should close doors to each client's room and move beds away from windows, and close window shades and curtains to protect clients, visitors, and staff from shattering glass and flying debris. Blankets should be placed over clients confined to bed. Ambulatory clients should be moved into the hallways from their rooms, away from windows
The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an assistive personnel (AP)? 1. A client requiring a colostomy irrigation 2. A client receiving continuous tube feedings 3. A client who requires urine specimen collections 4. A client with difficulty swallowing food and fluids
Answer: 3 Rationale: The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for the AP would be to care for the client who requires urine specimen collections. The AP is skilled in this procedure. Colostomy irrigations and tube feedings are not performed by APs because these are invasive p
The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. An assistive personnel (AP) is resistant to the change and is not taking an active part in facilitating the process of change. Which is the best approach in dealing with the AP? 1. Ignore the resistance. 2. Exert coercion on the AP. 3. Provide a positive reward system for the AP. 4. Confront the AP to encourage verbalization of feelings regarding the change
Answer: 4 Rationale: Confrontation is an important strategy to meet resistance head-on. Face-toface meetings to confront the issue at hand will allow verbalization of feelings, identification of problems and issues, and development of strategies to solve the problem. Option 1 will not address the problem. Option 2 may produce additional resistance. Option 3 may provide a temporary solution to the resistance but will not address the concern specifically
A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which scenario is characteristic of the team-based model of nursing practice? 1. Each staff member is assigned a specific task for a group of clients. 2. A staff member is assigned to determine the client's needs at home and begin discharge planning. 3. A single registered nurse (RN) is responsible for providing care to a group of 6 clients with the aid of an assistive personnel (AP). 4. An RN leads 2 licensed practical nurses (LPNs) and 3 APs in providing care to a group of 12 clients
Answer: 4 Rationale: In team nursing, nursing personnel are led by a registered nurse leader in providing care to a group of clients. Option 1 identifies functional nursing. Option 2 identifies a component of case management. Option 3 identifies primary nursing (relationship-based practice).
The nurse is giving a bed bath to an assigned client when an assistive personnel (AP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action? 1. Finish the bed bath and then administer the pain medication to the other client. 2. Ask the AP to find out when the last pain medication was given to the client. 3. Ask the AP to tell the client in pain that medication will be administered as soon as the bed bath is complete. 4. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.
Answer: 4 Rationale: The nurse is responsible for the care provided to assigned clients. The appropriate action in this situation is to provide safety to the client who is receiving the bed bath and prepare to administer the pain medication. Options 1 and 3 delay the administration of medication to the client in pain. Option 2 is not a responsibility of the AP.
The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first? 1. A client who is ambulatory demonstrating steady gait 2. A postoperative client who has just received an opioid pain medication 3. A client scheduled for physical therapy for the first crutch-walking session 4. A client with a white blood cell count of 14,000 mm3 (14 × 109 /L) and a temperature of 38.4° C
Answer: 4 Rationale: The nurse should plan to care for the client who has an elevated white blood cell count and a fever first, because this client's needs are the priority. The client who is ambulatory with steady gait and the client scheduled for physical therapy for a crutchwalking session do not have priority needs. Waiting for pain medication to take effect before providing care to the postoperative client is best.
The nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign four clients and has a licensed practical nurse and 3 assistive personnel (APs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical nurse? 1. A client who requires a bed bath 2. An older client requiring frequent ambulation 3. A client who requires hourly vital sign measurements 4. A client requiring abdominal wound irrigations and dressing changes every 3 hours
Answer: 4 Rationale: When delegating nursing assignments, the nurse needs to consider the skills and educational level of the nursing staff. Giving a bed bath, assisting with frequent ambulation, and taking vital signs can be provided most appropriately by an AP. The licensed practical nurse is skilled in wound irrigations and dressing changes and most appropriately would be assigned to the client who needs this care.