A nurse is assisting with the care of a client.

A nurse is reviewing the client's electronic medical record. Which of the following findings on day 7 require further action? Select all that apply.

A. Plan time at the end of the shift to document nursing interventions: Waiting until the end of the shift to document can lead to inaccuracies and missed details. It is more effective to document in real-time or immediately after providing care to ensure complete, accurate, and timely records, reducing errors and memory lapses.

B. Keep track of how long it takes to complete certain tasks: Monitoring how long tasks take helps the nurse better allocate time and identify where delays occur. This awareness allows for improved scheduling, more accurate prioritization, and realistic planning during the shift, leading to better time management.

C. Delegate collection of vital signs to the assistive personnel on the team: Delegating appropriate tasks, like vital signs collection, frees the nurse to focus on critical thinking, assessments, and interventions that require professional judgment. Proper delegation is an essential time-management strategy in providing efficient and safe client care.

D. Complete activities with one client before moving to another client: While thoroughness is important, it is not always efficient to rigidly finish all activities with one client before seeing others. Time-sensitive or urgent tasks with other clients may require interruptions, and flexibility is crucial for safe, effective care management.

E. Make a priority to do it at the beginning of the shift: Establishing priorities at the beginning of the shift ensures that essential and urgent needs are addressed promptly. Early planning helps organize tasks efficiently, reduces chaos during busy periods, and helps maintain focus throughout the shift.

A. The client tells the nurse he prefers a snack before bedtime: Client food preferences can usually be accommodated by nursing and dietary staff without needing interprofessional team intervention unless related to special dietary restrictions.

B. The client requires reinforcement of teaching about the purpose of his medications: Medication education reinforcement is a routine nursing responsibility and typically does not require escalation to the entire interprofessional team unless there are significant comprehension issues.

C. The client is unable to grasp eating utensils: Difficulty grasping utensils suggests significant motor deficits following the stroke. This functional limitation requires input from occupational therapy, physical therapy, and possibly speech therapy to assess needs for adaptive devices and rehabilitation strategies.

D. The client requests to perform ADLs later in the day: Adjusting the timing of ADLs is a minor scheduling preference and does not necessarily require interprofessional reporting unless it impacts therapy schedules or rehabilitation goals.