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A nurse is contributing to a quality improvement plan to improve the shift reporting process on the unit. Which of the following actions is the first step the nurse should suggest to promote a change in the reporting process?

A.

Review evidence-based literature to determine best practices in the shift reporting process.

B.

Organize a task force to review interventions to change the shift reporting process.

C.

Create a new shift reporting process to present at the next staff meeting.

D.

Develop a strategy to alert other nurses about the need for changes in the shift reporting process.

Answer and Explanation

The Correct Answer is A

A. Reviewing evidence-based literature is essential to understand best practices in shift reporting and can inform the development of effective interventions. This foundational step helps ensure that any proposed changes are supported by research and proven methods.  

 

B. While organizing a task force can be beneficial, it should occur after understanding the current best practices, as the task force's efforts would be better guided with existing evidence.  

 

C. Creating a new reporting process without first gathering information or reviewing best practices may result in ineffective or unnecessary changes.  

 

D. Developing a strategy to alert nurses is important, but it should be based on informed decisions derived from literature and data analysis, which should come first.


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Correct Answer is C

Explanation

A. While the nurse's notes may include observations about the client's condition, recording that an incident report was filed does not provide pertinent details regarding the client's care and is not appropriate.

B. Incident reports are confidential documents and should not be shared with the client's family, so providing a copy of the report is inappropriate.

C. Documenting the facts about the incident in the medical record is essential to provide a complete account of the client's care and any resulting changes or observations. This documentation is important for continuity of care and legal purposes.

D. Incident reports should not be placed in the medical record, as they are separate documents intended for internal review and quality assurance purposes.

Correct Answer is D

Explanation

A. QD (every day) is not an approved abbreviation due to the potential for misinterpretation, so it should not be used.

B. HS (at bedtime) is also not recommended as it can be confused with "half-strength," so it is not an approved abbreviation.

C. SQ (subcutaneous) is not commonly used in current practice as abbreviations may lead to errors; the term should be written out as "subcut" or "subcutaneously."

D. PO (by mouth) is an accepted and approved abbreviation used to indicate that a medication is to be taken orally, making it the correct choice for inclusion in the in-service.

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