Author Question: The nurse is implementing care and treatments for assigned clients. What actions should the nurse ... (Read 59 times)

hubes95 · **on:** Jul 23, 2018

The nurse is implementing care and treatments for assigned clients. What actions should the nurse prepare to complete during this phase of the nursing process?

1. Evaluating the outcome of the interventions
2. Reassessing the client
3. Documenting the history and physical
4. Supervising delegated care
5. Implementing the nursing intervention

Question 2

The nurse assigns unlicensed assistive personnel to measure vital signs for several clients. The task is completed and documented correctly; however, one of the clients had a blood pressure reading of 180/110.

The nurse learns this information at the end of the shift. Which responsibility of delegation did the nurse fail to carry out?
1. Delegating to the appropriate staff
2. Delegating the appropriate task
3. Selecting the appropriate client
4. Appropriately supervising care

daiying98 · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Correct Answer: 2, 4, 5
Rationale 1: Evaluating the outcome of the interventions is part of the evaluation phase.
Rationale 2: This is a component of the implementation process.
Rationale 3: Documentation of the history and physical is part of the initial assessment.
Rationale 4: This is a component of the implementation process.
Rationale 5: This is a component of the implementation process.

Answer to Question 2

Correct Answer: 4
Rationale 1: The nurse did delegate to the appropriate staff, as securing vital signs is within the scope of practice for unlicensed assistive personnel.
Rationale 2: The nurse did delegate an appropriate task, as securing vital signs is within the scope of practice for unlicensed assistive personnel.
Rationale 3: There was no indication given that the clients were not appropriately selected for this task.
Rationale 4: The nurse has two responsibilities in delegating and assigning duties: (1) appropriate delegation of duties (that is, giving people duties within their scope of practice) and (2) adequate supervision of personnel to whom work is delegated or assigned. In this situation, the nurse gave an unlicensed person a duty that was appropriate. Unlicensed assistive personnel completed the duty and documented the findings. The nurse is still responsible for analyzing data, planning care, and evaluating outcomes. In this case, the nurse failed to follow up (supervise) after the duty was performed and analyze the findings.