A nurse is caring for four clients who are postoperative from surgery 24 hr ago. At 1200 the nurse assesses the clients. Which of the following clients is the nurse's priority?
A client who reports pain as 4 on a scale of 1 to 10 at 0800 now reports pain as 6
A client whose wound drainage at 0800 was sanguineous and now it is serosanguineous
A client who has a prescription for insulin and his premeal capillary blood glucose was 110 mg/dL and his post-meal capillary blood glucose is now 160 mg/dL
A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg
The Correct Answer is D
Rationale:
A. A client who reports pain as 4 on a scale of 1 to 10 at 0800 now reports pain as 6 needs pain management, but this is less urgent compared to potential signs of hypotension.
B. A client whose wound drainage at 0800 was sanguineous and now it is serosanguineous indicates normal progression of wound healing; thus, it is less critical.
C. A client who has a prescription for insulin and his premeal capillary blood glucose was 110 mg/dL and his post-meal capillary blood glucose is now 160 mg/dL needs blood glucose management, but this is less urgent than assessing for potential hypovolemia or shock.
D. A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg is experiencing a significant drop in blood pressure, which could indicate hypovolemia or shock. This requires immediate assessment and intervention to prevent complications.
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Correct Answer is C
Explanation
Rationale:
A. Informing the staff member of her appraisal time for that day prior to change-of-shift report is not ideal as it may disrupt the shift handover process.
B. Scheduling the appraisal interview as early in the shift as possible might not be feasible or considerate, especially if it impacts patient care or the staff member's workflow.
C. Providing the staff member with a copy of the appraisal form in advance is best practice as it allows the staff member to prepare for the discussion and address any concerns or achievements.
D. Providing a chair directly across the desk for the staff member to sit in is not as important as preparing the staff member by sharing the appraisal criteria in advance.
Correct Answer is A
Explanation
Rationale:
A. Comparing the number of medication errors before and after implementing changes provides a direct measure of the effectiveness of those changes.
B. Conducting a study on costs is relevant but not directly related to evaluating the effectiveness in reducing medication errors.
C. Establishing a benchmark is useful for setting standards but does not measure the impact of changes already implemented.
D. Quantifying staff satisfaction is important for assessing the acceptance of changes but does not directly measure the effectiveness in reducing errors.