A nurse is prioritizing care for four clients. Which of the following tasks should the nurse perform first?
Initiate oxygen therapy via nasal cannula for a client who has COPD.
Initiate a 24-hr urine collection for a client who has end-stage kidney disease.
Administer an antibiotic for a client who has methicillin-resistant Staphylococcus aureus.
Change the dressing for a client who has a decubitus ulcer.
The Correct Answer is A
A. Initiating oxygen therapy for a client with COPD is a priority because oxygenation is critical for clients with respiratory conditions. Hypoxia can lead to serious complications, making this intervention urgent.
B. While initiating a 24-hour urine collection is important for monitoring kidney function, it does not require immediate action compared to the need for oxygen therapy in a client with respiratory distress.
C. Administering antibiotics is essential, especially for a client with an infection like MRSA; however, the need for immediate oxygen therapy takes precedence over medication administration.
D. Changing the dressing for a decubitus ulcer is important for preventing infection and promoting healing but is not as time-sensitive as ensuring adequate oxygenation for the client with COPD.
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Correct Answer is D
Explanation
A. Identifying clients by room number instead of name does not adequately protect client confidentiality, as room numbers can still be linked to specific patients.
B. Logging assistive personnel into unit computers for documentation undermines security measures, as each user should have their unique login credentials.
C. Placing the client's name on the cover sheet when faxing protected health information violates confidentiality and can lead to unauthorized access to sensitive data.
D. Conducting change-of-shift reports in a designated staff-only area ensures that client information is not overheard by unauthorized individuals, maintaining confidentiality.
Correct Answer is D
Explanation
A. Selecting an intervention is a subsequent step and should be informed by the baseline data on infection rates.
B. Incorporating the change into daily practice is necessary later in the process, once a specific intervention has been chosen and planned.
C. Determining if the change has lowered the infection rate is part of the evaluation phase, following the implementation of interventions.
D. Identifying current infection rates provides baseline data, which is essential for measuring the effectiveness of future interventions. Without this data, it is impossible to determine whether any implemented changes result in improvement.