A charge nurse is determining client acuity levels. The nurse should consider the time spent completing which of the following tasks when determining acuity?
Assisting others
Medication administration
Meal breaks
Charting
The Correct Answer is B
A. While assisting others is an important aspect of nursing care, it generally does not directly reflect the acuity of clients. Assisting colleagues might involve helping with tasks, offering support, or collaborating on care, but it is more related to teamwork and overall unit dynamics rather than directly indicating the complexity or intensity of care needed by individual clients.
B. Medication administration is a significant factor in determining client acuity. The complexity and frequency of medications, the need for monitoring and adjustments, and the administration of high-risk medications (e.g., anticoagulants, insulin) all contribute to the overall acuity level. High acuity clients often require more complex medication management, which demands more time and attention from nursing staff.
C. Meal breaks are a necessary part of a nurse’s schedule but are not related to client acuity. Meal breaks are periods of rest and are essential for maintaining the nurse’s well-being and productivity. However, they do not affect the level of care required by clients or the determination of client acuity.
D. Charting is a crucial component of nursing care that reflects the time spent documenting client information, assessments, and care provided. While charting is essential for legal documentation, communication, and continuity of care, it is not a direct indicator of client acuity.
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Related Questions
Correct Answer is ["B","C","D"]
Explanation
A. A client who is easily distracted during art therapy may benefit from being near the nurses' station if their distraction could lead to issues with concentration or focus that might impact their therapy.
However, this is less of a priority compared to clients with higher risks related to safety or behavioral issues. This client’s needs are more about support and engagement in therapy rather than immediate safety monitoring.
B. Clients with frequent anger outbursts can pose a risk to themselves and others. Having them in a room near the nurses' station allows for closer monitoring and quick intervention if their behavior escalates. This placement helps ensure safety and provides immediate access to staff if the client becomes agitated or poses a threat.
C. A client who has threatened to kill themselves requires close observation to ensure their safety and prevent self-harm. Placing this client in a room near the nurses' station allows for constant monitoring and immediate intervention if the client’s condition worsens or if they attempt self-harm. This is a high priority for safety and supervision.
D. A client who has engaged in cutting behaviors is at risk for self-harm. Placing this client near the nurses' station is important for ensuring close observation and timely intervention to prevent further self-injury. This helps in providing a safer environment and immediate support if the client shows signs of distress or attempts self-harm.
E. A client who cannot sit still at breakfast might need supervision to ensure they eat properly and safely. However, this need is less critical compared to clients with high risks of self-harm or aggressive behaviors. While this client may benefit from being in a more monitored area, it is not as urgent as the needs of clients with significant safety concerns.
Correct Answer is D
Explanation
A. Assessment involves collecting and analyzing data about the client's health status, including their medical history, physical examination findings, and any other relevant information. This step is crucial for understanding the client's current condition and needs, but it precedes goal setting.
B. Evaluation is the step where the nurse determines whether the goals and outcomes established in the planning phase have been achieved. It involves assessing the effectiveness of interventions and making adjustments as needed. Evaluation occurs after goals have been set and interventions have been implemented, so it is not the step where goals are initially formulated.
C. Implementation involves carrying out the interventions and actions planned to achieve the goals established for the client. This step follows the formulation of goals and involves executing the planned care. While critical to achieving positive outcomes, implementation does not include the initial formulation of goals.
D. Planning is the step of the nursing process where the nurse formulates goals and develops a plan of care based on the assessment data. This includes setting specific, measurable, achievable, relevant, and time-bound (SMART) goals to guide the care provided and achieve positive client outcomes. Planning is where goals are established to address the client’s identified needs and guide subsequent interventions.
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