19 hours ago The nurse has just finished the change-of-shift report. Which patient should the nurse assess first? a. The patient who needs assistance transferring from the bed to a wheelchair b. The client with COPD who is having difficulty breathing c. A client who is being discharged today d. An elderly client who has requested medication for pain >> Go To The Portal
Which client should the nurse assess first? 1. The client with Guillain-Barré syndrome who has ascending paralysis to the knees. 2. The client with a C-6 spinal cord injury who has autonomic dysreflexia.
The nurse is the first person on the scene of a motor vehicle accident. The driver is in the driver's seat unconscious. Which action should the nurse implement first? 1. Stabilize the driver's cervical spine. 2. Do not move the client from the accident. 3. Ensure the driver has a patent airway. 4. Control any external bleeding
The nurse in the vascular critical care unit is working with an LPN who was pulled to the unit as a result of high census. Which task is most appropriate for the nurse to assign to the LPN? Stop the transfusion at the hub. The nurse is administering one unit of packed red blood cells to a client.
The concept of a handoff is complex and “includes communication between the change of shift, communication between care providers about patient care, handoff, records, and information tools to assist in communication between care providers about patient care”1(p. 1).
The nurse has received the shift report. Which client should the nurse assess first? Assess the client for abnormal bleeding.
Begin first with the patient who has the highest priority and progress to the patient who has the lowest priority. A nurse is performing a complete physical assessment of an adolescent.
Nursing Prioritization and the NCLEX-RN The nurse should plan care to meet physiological needs first, followed by safety needs, love and belonging needs, and so on. As a test-taker, you can use Maslow's Hierarchy of Needs to help you decide which to choose.
Nurse triage is needed in a number of situations, including within the emergency department. The nurse must assess which client is at the highest risk of being in a life-threatening situation. The first client who must be assessed is the one who has a situation that threatens the airway, breathing, or circulation.
In triage, a nurse typically prioritizes each patient's condition into one of three general categories: Immediately life threatening. Urgent, but not necessarily immediately life threatening. Less urgent.
0:309:32Patient Prioritization for fundamentals. Part 1 - YouTubeYouTubeStart of suggested clipEnd of suggested clipNow obviously anyone who does have an airway breathing or circulation issue comes first in terms ofMoreNow obviously anyone who does have an airway breathing or circulation issue comes first in terms of priority.
Nurses should apply the concept of ABCs to each patient situation. Prioritization begins with determining immediate threats to life as part of the initial assessment and is based on the ABC pneumonic focusing on the airway as priority, moving to breathing, and circulation (Ignatavicius et al., 2018).
The first-level priority problems are health issues that are life-threatening and require immediate attention. These are health problems associated with ABCs; airway, breathing, and circulation, such as establishing an airway, supporting breathing, and addressing sudden perfusion and cardiac issues.
assessmentThe nursing process functions as a systematic guide to client-centered care with 5 sequential steps. These are assessment, diagnosis, planning, implementation, and evaluation. Assessment is the first step and involves critical thinking skills and data collection; subjective and objective.
Terms in this set (59) In what order should the nurse assess assigned clients following shift report? Place in priority order.
Emergent care is medical care that directly addresses threats to life, limb, or eyesight.
Red-tagged clients have major injuries, black-tagged clients are expected and allowed to die, and yellow-tagged clients have major injuries.
A: Some basic time management strategies include outcome orientation (not delivery), an analysis of the cost of use of time, a focus upon prioritie...
D: Effective shift planning involves deciding what goals or outcomes they want to achieve. Identifying optimal outcomes (best possible objectives),...
B: A definition of time management is “a set of related common-sense tools that helps you use your time in the most effective and productive way po...
A: The Pareto principle is based upon the prioritization of work effort through such measures as managing one’s time effectively. The basic premise...
B: Unfortunately, many people still function in the crisis mode to get things done. An example of this would be a student who does not study for an...
C: It is important, when making long-term goals and outcomes, that they remain flexible. The concept of flexibility should be built into any outcom...
D: The activity log is a time management tool in which behaviors are logged consistently over a period of days to determine how time is spent. Nurs...
C: Outcomes can be categorized in a variety of different groups. Reasonable (realistic) outcomes are those that can reasonably be expected to occur...
D: Prioritizing care is one means nurses have of organizing their patient care. Life-threatening or potentially life-threatening conditions (such a...
The nurse notifies the physician and obtains correct and complete medication orders, thereby avoiding a potentially serious medication error.
The transfer of essential information and the responsibility for care of the patient from one health care provider to another is an integral component of communication in health care. This critical transfer point is known as a handoff.1–3 An effective handoff supports the transition of critical information and continuity of care and treatment. However, the literature continues to highlight the effects of ineffective handoffs: adverse events and patient safety risks.4–11 The Institute of Medicine (IOM) reported that “it is in inadequate handoffs that safety often fails first”12 (p. 45). This chapter presents an overview of handoffs, a summary of selected literature, gaps in the knowledge, and suggestions for quality improvement initiatives and recommendations for future research.
The intershift handoff is influenced by various factors, including the organizational culture. An organization that promotes open communication and allows all levels of personnel to ask questions and express concerns in a nonhierarchical fashion is congruent with an environment that promotes a culture of safety.58Interes tingly, one study reported novice nurses seeking information approached those seen as “less authoritarian.”84The importance of facilitating communication is critical in promoting patient safety. The shift-to-shift handoff is a multifaceted activity.78, 85, 86A poor shift report may contribute to an adverse outcome for a patient.55
The challenge during handoffs across settings and times is to identify methods and implement strategies that protect against information decay and funneling,66contributing to the loss of important clinical information. It is a challenge to develop a handoff process that is efficient and comprehensive, as case studies illustrate.57, 88, 92, 93Observation of shift handoffs reveals that 84.6 percent of information presented in handoffs could be documented in the medical record.42A concern that emerged in this study was some handoff reports actually “promote confusion,” and therefore the authors advocated improving the handoff process.42
Handoffs occur across the entire health care continuum in all types of settings. There are different types of handoffs from one health care provider to another, such as in the transfer of a patient from one location to another within the hospital64or the transition of information and responsibility during the handoff between shifts on the same unit.1, 41, 43Interdisciplinary handoffs occur between nurses and physicians, and nurses and diagnostic personnel, while intradisciplinary handoffs occur between physicians3, 15, 31or between nurses.13, 14, 41, 42,43Interfacility handoffs occur between hospitals and among multiple organizations,68including home health agencies,69, 70hospices,71and extended-care facilities.72, 73
The transfer of essential information and the responsibility for care of the patient from one health care provider to another is an integral component of communication in health care. This critical transfer point is known as a handoff.1–3An effective handoff supports the transition of critical information and continuity of care and treatment. However, the literature continues to highlight the effects of ineffective handoffs: adverse events and patient safety risks.4–11The Institute of Medicine (IOM) reported that “it is in inadequate handoffs that safety often fails first”12(p. 45). This chapter presents an overview of handoffs, a summary of selected literature, gaps in the knowledge, and suggestions for quality improvement initiatives and recommendations for future research.
A phenomenon well known to nurses is the use of nurse-developed notations, “cheat sheets” or “scraps” of information, while receiving or giving intershift reports. A study of such note taking found scraps are used for a variety of purposes, including creating to-do lists and recording specific information and perceptions about the patient and family.87This approach presents some challenges, as no one else has easy access to the information; therefore, continuity of care may be compromised during a meal break, for example, or if the scrap or cheat sheet is misplaced.
The UAP places her hand under the client's right axilla to help the client move up in bed.
1. Feed the client who is being allowed to eat for the first time. 2. Administer the client's anticoagulant subcutaneously. 3. Check the client's neurological signs and limb movement. 4. Teach the client to turn the head and tuck the chin to swallow. Administer the client's anticoagulant subcutaneously.
As a nurse, you are assigned to four patients. Which patient do you need to see first?
The licensed practice nurse (LPN) provides you with the change-of-shift vital signs on four of your patients. Which patient do you need to assess first?
A charge nurse overhears an unlicensed assistive personnel (UAP) speaking harshly to a patient who has an expressive aphasia and a left hemiparesis from a stroke. When the UAP leaves the room, the charge nurse decides to speak with her. How should the nurse respond to the situation?
A patient is hospitalized for depression and suicidal ideation after their spouse asks for a divorce. Select the nurse's most caring comment.
The nurse allows a postoperative patient to decide to take medication with fruit juice rather than water.
An RN who has been a nurse for 10 years is precepting a novice RN. The novice is having difficulty prioritizing patient care. What should the RN tell the novice about the principles of prioritizing care?
A middle-aged woman is referred for a mammogram. What level of illness prevention is being practiced in this situation?
The nurse and the unlicensed assistive personnel are caring for clients on a vascular unit. Which task is most appropriate for the nurse to delegate?
Contact the local fire department to see if they can provide smoke detectors for the client. The home health (HH) nurse has completed a home assessment on a client and finds out there are no smoke detectors in the home. The client tells the nurse they just cannot afford them.