Which information will the nurse consider when deciding what nursing actions to delegate to a licensed practical/vocational nurse (LPN/VN) who is working on a medical-surgical unit?

Choice A: Collect patient information

The first step in the nursing process is to collect patient information, also known as the assessment phase. During this phase, the nurse gathers comprehensive data about the patient’s health status, including medical history, physical examination findings, and any relevant diagnostic test results. This information forms the foundation for identifying the patient’s needs and planning appropriate care.

Choice B: Identify any clinical problems

After collecting patient information, the next step is to identify any clinical problems, also known as the diagnosis phase. In this phase, the nurse analyzes the assessment data to determine the patient’s health issues or potential risks. This step involves critical thinking and clinical judgment to prioritize the patient’s problems and develop a nursing diagnosis.

Choice C: Decide a plan of action

The third step is to decide a plan of action, also known as the planning phase. During this phase, the nurse sets measurable and achievable goals for the patient’s care based on the identified clinical problems. The nurse also develops specific interventions to address these problems and achieve the desired outcomes. This plan serves as a guide for the subsequent implementation phase.

Choice D: Carry out the plan

The fourth step is to carry out the plan, also known as the implementation phase. In this phase, the nurse executes the planned interventions to address the patient’s clinical problems. This may involve administering medications, providing treatments, educating the patient and family, and coordinating care with other healthcare professionals. The nurse continuously monitors the patient’s response to the interventions and makes adjustments as needed.

Choice E: Determine whether the plan was effective

The final step is to determine whether the plan was effective, also known as the evaluation phase. During this phase, the nurse assesses the patient’s progress toward the established goals and evaluates the effectiveness of the interventions. If the desired outcomes are not achieved, the nurse may need to revise the plan and implement new strategies. This ongoing evaluation ensures that the patient’s care is continuously improved and optimized.

Choice A: Properly cleaning all reusable equipment once each day

While cleaning reusable equipment is important, it should be done after each use, not just once a day. This ensures that any potential pathogens are removed before the equipment is used on another patient, thereby preventing cross-contamination.

Choice B: Appropriately using PPE

This is a correct answer. Personal Protective Equipment (PPE) such as gloves, masks, gowns, and eye protection are essential in preventing the spread of infection. Proper use of PPE helps protect both healthcare workers and patients from exposure to infectious agents.

Choice C: Ensuring all environmental surfaces are properly cleaned, disinfected, and maintained

This is another correct answer. Regular cleaning and disinfection of environmental surfaces, such as bed rails, doorknobs, and medical equipment, are crucial in preventing the spread of infections. Maintaining a clean environment reduces the risk of healthcare-associated infections.

Choice D: Avoiding all invasive interventions

Avoiding invasive interventions is not a practical or realistic approach to preventing infections. While minimizing unnecessary invasive procedures can reduce infection risk, many invasive interventions are necessary for patient care. Instead, proper aseptic techniques should be used during these procedures to prevent infections.

Choice E: Performing hand washing or using an alcohol-based hand sanitizer before and after patient contact or procedures

This is also a correct answer. Hand hygiene is one of the most effective measures to prevent the spread of infections. Washing hands with soap and water or using an alcohol-based hand sanitizer before and after patient contact or procedures significantly reduces the transmission of pathogens.