Module 3 Clinical decision making

A nurse is in a dangerous situation where the client is showing signs of aggression. The nurse needs to do which of the following to prevent an accident.

• Tell the client to calm down

• Throw things at the client

• Create a barrier from the nurse to the client

• Make sure to record

A nurse is teaching new grad nurses about delegating. Which of the following indicates understanding of delegation.

• " I am allowed to delegate to the CNA and the RN"

• " I am allowed to delegate tasks to the CNA"

• " I as a LPN am allowed to delegate to an RN

• " I can not delegate to anyone"

A client talks about not feeling wanted. The client states that they feel like and outcast when among a large group of people. You as the nurse should recognize that the client is not meeting which level of maslows.

• Physiological needs because the big group will not let the client sleep or have water

• Safety because the big group makes them feel scared and unsafe

• Love and belonging because when in a big group they feel like and outcast and are unwanted

• The client is meeting all of these

A nurse is doing an assessment on a patient. The patient states that they are having trouble breathing when they lay down. You as the nurse when documenting should put this under which of the following

• Assessment because it came about during the assessment

• Subjective because the client stated it

• Objective because you can see that they are having trouble

• Planning so that you can let the doctor know the plan

A client has fallen. You as the nurse need to use the nursing process to know what to do next. The client has already stated that he fell while getting up to get the remote. He has pain in the back of his head and rated it a 7 out of 10. Which is your next step

• Implement a way to notify the provider

• Analyze the data the patient has giving you about his pain and the situation

• Plan on how to get the patient off of the floor and back into the bed

• Evaluate his head and make sure he is ok

Time management is very important in a nurses shift. Prioritizing your time will help you get more tasks done. You have 3 client who need medication scheduled for after lunch, a client who needs an IV stat, and a client who needs help to the bathroom. You have to complete these tasks in time for lunch. How would you do this

• Ask another nurse to help you because you don't want to do any of this.

• Give the medicine now because it will not hurt them, Start the IV after lunch and help the client to the bathroom now

• Start the IV now since it was ordered Stat, Then delegate the client that needs help to the bathroom to an AP, then after lunch give the medicine

• Give the medicine while you start the IV and then help the client to the bathroom

As the nurse it is important that the client knows about everything going on. When prescribing medications one thing to happen is noncompliant responses, You as the nurse need to do which of the following to help insure safety for the client

• Provide client education such as how much to take, when to take it, and when to come see the doctor for a checkup

• Let them read the directions and call if they have any comments

• Let the client figure it out on their own, that is the only way they will learn

• Explain that you are only the nurse and know just as much as the client does

When communicating it is important to be clear about what you are saying, Miscommunication happens a lot in health care. To help prevent it you as a nurse can

• Talk fast and soft to save time so you can get back to work. It is fine if they can not hear you that is their fault not yours

• Ask someone else to communicate for you

• Sum everything up, the other nurses should know what you are talking about

• Speak clearly and give extra tips on how to improve a task. Make sure to give all the information and not sum it up

When rationing it is important to not overwhelm yourself or others, never ration more than one person can handle. There are 11 patients and two nurses, using the nursing process what is one thing you can do to help make things go smoother.

• Call for another nurse, explain that you need another pair of hands and that it would be safer for the clients and you, There will be less room for mistakes.

• Simply walk away leaving the other nurse by herself, Better her than you. It is just impossible to find another solution

• Split the 11 patients and just try your best to get everything done

• See which one of you wants to take an extra patient so that the other person isn't has overwhelmed, Better one than two overwhelmed nurses

As a nurse you are also an educator, When discharging make sure to ask the client if they have any questions, Some ways to help them understand is

• Instruct them to look it up on the internet and call if they have any other questions

• Tell them to ask the doctor the next time they see the doctor

• Give pamphlets, links to websites, and instruction on how to take medications

• Simply tell them that the doctor will explain everything later