A nurse has just received change-of-shift report for a group of clients. Which of the following strategies should the nurse use to help manage client care requirements throughout the shift?
Set specific times for low-priority tasks.
Perform complicated tasks independently.
Postpone checking for new prescriptions until medications are due.
Cluster care activities for each client.
The Correct Answer is D
A. Setting specific times for low-priority tasks may not be the most efficient use of time, as client needs can change throughout the shift.
B. Performing complicated tasks independently may not be safe, as it is essential to collaborate with other healthcare team members when necessary for patient safety.
C. Postponing checking for new prescriptions until medications are due could lead to delays in care and negatively impact client outcomes; it's important to check for updates promptly.
D. Clustering care activities for each client promotes efficiency, minimizes interruptions, and helps ensure that all care needs are met in a timely manner.
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Correct Answer is B
Explanation
A. Removing gloves before leaving an isolation room is appropriate practice and helps prevent the spread of infection.
B. Filling a basin with water at 40° C (104° F) is too hot for foot care and could lead to burns or injury; water temperature for foot care should be comfortably warm, typically around 37°C (98.6°F).
C. Instructing a client to look down at their feet when being assisted to ambulate is a safety measure that can help the client maintain balance and avoid tripping.
D. Applying water-soluble lubricant to the nares of a client receiving oxygen is a standard practice to prevent dryness and does not require intervention.
Correct Answer is A
Explanation
A. Reporting the concern to the charge nurse is the appropriate action, as it ensures that the issue is addressed through proper channels. The charge nurse can investigate and determine if further action is needed, such as reviewing the medication administration process.
B. Questioning the nurse directly could lead to confrontations and is not the correct procedure for handling potential discrepancies in medication administration.
C. Notifying the pharmacy is unnecessary at this point because the issue concerns administration rather than medication supply or errors with the prescription.
D. While documenting the client’s report is important, simply documenting the client’s claim without notifying the charge nurse does not fully address the concern.