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A nurse is receiving change-of-shift report at the start of the shift. Which of the following statements by the nurse giving report indicates to the oncoming nurse that she should assume total care for the client, rather than assigning tasks to the assistive personnel (AP)?
- A. The client works in the hospital radiology department.
- B. The client discussed having prior thoughts of suicide.
- C. The client's blood pressure and pulse have been fluctuating throughout the day.
- D. The client's family members have been present most of the day.
Correct Answer: C
Rationale: The correct answer is C because fluctuating blood pressure and pulse indicate unstable vital signs requiring close monitoring and immediate intervention. The nurse giving report is indicating that the client's condition is dynamic and may require frequent assessments and interventions, which necessitates the oncoming nurse assuming total care. Choices A, B, and D do not directly imply the need for total care and could potentially be managed by assistive personnel.
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A charge nurse is evaluating the performance of an assistive personnel (AP). Which of the following actions by the AP indicates a need for further education?
- A. The AP reports a client's temperature of 38.5°C to the nurse.
- B. The AP assists a client with turning every 2 hours.
- C. The AP leaves a client's meal tray out of reach after delivery.
- D. The AP uses a gait belt when ambulating a client.
Correct Answer: C
Rationale: Leaving the meal tray out of reach prevents the client from eating, indicating a need for further education on client-centered care. The other actions are appropriate.
A nurse is preparing a report for the quality improvement committee about medication errors. Which of the following data should the nurse include to evaluate the effectiveness of current interventions?
- A. The number of staff trained on medication safety protocols.
- B. The cost of implementing new medication scanners.
- C. The percentage of medication errors before and after interventions.
- D. The satisfaction scores from staff using new medication systems.
Correct Answer: C
Rationale: The correct answer is C, the percentage of medication errors before and after interventions. This data is crucial for evaluating the effectiveness of current interventions because it directly measures the impact of the interventions on reducing medication errors. By comparing the percentage of errors before and after the interventions, the nurse can determine if the interventions have been successful in improving medication safety.
Choice A is incorrect because while staff training is important, it does not directly measure the effectiveness of interventions on reducing errors.
Choice B is incorrect as the cost of implementing new scanners is not a direct indicator of effectiveness in reducing medication errors.
Choice D is incorrect as staff satisfaction scores do not necessarily reflect the actual impact on medication error reduction.
In summary, monitoring the percentage of medication errors before and after interventions provides a clear, objective measure of the effectiveness of current interventions in improving medication safety.
A nurse and an assistive personnel (AP) are providing care for four clients who were admitted to the medical-surgical unit on the previous shift. The nurse should delegate meal assistance for which of the following clients to the AP?
- A. A client who has Guillain-Barre syndrome
- B. A client who has a lumbosacral spinal tumor
- C. A client who has systemic sclerosis
- D. A client who has amyotrophic lateral sclerosis (ALS)
Correct Answer: B
Rationale: The correct answer is B. A client with a lumbosacral spinal tumor may need assistance with meals due to potential mobility limitations or weakness. The nurse can delegate this task to the AP as it falls within their scope of practice. Clients with Guillain-Barre syndrome (choice A) may have muscle weakness and difficulty swallowing, requiring skilled nursing assessment during mealtime. Clients with systemic sclerosis (choice C) may have gastrointestinal involvement, necessitating careful monitoring during meals. Clients with ALS (choice D) have progressive muscle weakness, making it crucial for a nurse to assess their ability to eat safely. Delegating meal assistance for these clients to an AP may compromise their safety.
A nurse manager is reviewing incident reports from the past month. Which of the following situations should the nurse prioritize for follow-up?
- A. A client received a meal tray with the wrong diet.
- B. An assistive personnel failed to report a client's low blood glucose level.
- C. A nurse documented a medication administration 30 minutes late.
- D. A client's call light was answered after a 10-minute delay.
Correct Answer: B
Rationale: The correct answer is B. Prioritizing follow-up on the assistive personnel's failure to report a client's low blood glucose level is crucial as it directly impacts patient safety and could lead to serious consequences. Not reporting a critical health issue promptly can result in harm or even death. Addressing this issue promptly is essential to prevent recurrence and ensure the well-being of the patient. Choices A, C, and D involve errors or delays that are concerning but do not pose an immediate threat to patient safety compared to the failure to report a critical health issue.
A nurse is delegating client care assignments for the shift. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?
- A. Teach a client about low-sodium foods.
- B. Measure and record intake and output for a client.
- C. Perform wound irrigation for a client.
- D. Evaluate pain relief for a client following the administration of a pain medication.
Correct Answer: B
Rationale: The correct answer is B: Measure and record intake and output for a client. This task can be safely delegated to an assistive personnel (AP) as it is a non-invasive and routine task that does not involve critical thinking or interpretation. APs are trained to perform basic tasks like measuring and recording intake and output accurately under the supervision of a nurse. Other choices are incorrect because: A involves providing client education which requires critical thinking and assessment skills, C involves a procedure that requires specific training and skill, and D involves evaluating the effectiveness of pain relief which requires nursing judgment and assessment skills.