A nurse administrator is using benchmarking as control criteria while reviewing current policies and procedures. Which of the following actions should the nurse take?

Determine how current practice will affect future performance within the facility.

Compare practices within the facility against other high-performing facilities.

Establish work initiatives to promote a positive environment.

Use root cause analysis to identify gaps in meeting standards.

Answer and Explanation

The Correct Answer is B

A.   Determine how current practice will affect future performance within the facility: While this is an important consideration for improving performance, it does not directly involve benchmarking against external standards or practices.
B.   Compare practices within the facility against other high-performing facilities: This is the correct answer. Benchmarking involves comparing the organization's practices, processes, and performance metrics against those of other high-performing organizations or industry standards to identify areas for improvement and best practices.
C.   Establish work initiatives to promote a positive environment: While promoting a positive work environment is important for organizational success, it is not directly related to benchmarking as control criteria.
D.   Use root cause analysis to identify gaps in meeting standards: Root cause analysis is a method used to identify underlying causes of problems or failures. While it may be part of a quality improvement process, it is not specifically related to benchmarking.

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Correct Answer is A

Explanation

- A. A client with a compromised airway requires immediate intervention to secure breathing, which is a top priority in triage situations. Without a patent airway, the client is at high risk for suffocation and rapid deterioration.
- B. A client who experienced a brief loss of consciousness may require observation and further assessment, but does not necessarily need immediate life-saving intervention if consciousness has been regained and there are no other signs of airway, breathing, or circulation compromise.
- C. A client with fixed pupils may indicate severe brain injury and, depending on the context, could be considered for a red tag. However, without additional information on breathing and circulation status, it is not the most definitive choice for immediate intervention.
- D. A client with major burns covering 70% of their body is critically injured and will require extensive medical care, but the immediate life-threatening issue in a triage situation is the airway compromise, not the burns themselves.

A. Elevates the head of the client's bed to 30° before inserting a nasogastric tube B. Maintains the chest tube collection device below the level of the insertion site when ambulating the client C. Assists the client into a fetal position on his side in preparation for a lumbar puncture D. Assesses the client's gag reflex following an esophagogastroduodenoscopy

Correct Answer is A

Explanation

A. Elevating the head of the client’s bed to 30° before inserting a nasogastric (NG) tube is incorrect. The proper position for NG tube insertion is typically with the client sitting upright at 45–90° to reduce the risk of aspiration and facilitate the passage of the tube through the esophagus. This action requires intervention by the charge nurse to correct the positioning.

B. Maintaining the chest tube collection device below the level of the insertion site when ambulating the client is correct. This positioning prevents backflow of drainage into the pleural space, which could lead to complications such as pneumothorax or infection. No intervention is needed for this action.

C. Assisting the client into a fetal position on their side in preparation for a lumbar puncture is correct. This position helps to widen the spaces between the vertebrae, allowing easier access to the spinal canal for the procedure. This action does not require intervention.

D. Assessing the client’s gag reflex following an esophagogastroduodenoscopy (EGD) is correct. After an EGD, the client’s gag reflex must return before allowing oral intake to prevent aspiration. This action does not require intervention.

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A nurse administrator is using benchmarking as control criteria while reviewing current policies and procedures. Which of the following actions should the nurse take?

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