A nurse working on a cardiac unit delegated taking vital signs to an experienced unlicensed assistive personnel (UAP). Four hours later, the nurse notes the client's blood pressure is much higher than previous readings & the client's mental status has changed. What action by the nurse would most likely have prevented this negative outcome?

Correct Answer: C

Rationale: The correct answer is C: Providing more appropriate supervision of the UAP. By providing adequate supervision, the nurse can ensure that the UAP is performing tasks correctly and can intervene if any issues arise. This would have likely prevented the negative outcome as the nurse could have identified the high blood pressure and changed mental status earlier. A: Determining if the UAP knew how to take blood pressure - While assessing the UAP's competence is important, it does not address the need for ongoing supervision and oversight. B: Double-checking the UAP by taking another blood pressure - This approach does not address the root cause of the issue, which is the lack of appropriate supervision. D: Taking the blood pressure instead of delegating the task - This is not a sustainable solution as delegating tasks to UAPs is a common practice in healthcare settings. Providing appropriate supervision is key to ensuring safe and effective delegation.

Correct Answer: B

Rationale: The correct answer is B because even as a new nurse, one can contribute to improving care by implementing activities. This response encourages the new nurse to actively engage in the quality improvement process, fostering a sense of ownership and commitment to enhancing patient outcomes. Choice A is incorrect as participation in QI projects is not solely based on tenure. Choice C is incorrect as identifying indicators requires knowledge and experience. Choice D is incorrect as it suggests a specific assignment rather than empowering the new nurse to take initiative in improving care.

Correct Answer: D

Rationale: The correct answer is D because utilizing the SHARE model helps standardize hand-off reports and communication. 1. S stands for Situation: providing context. 2. H stands for History: outlining relevant information. 3. A stands for Assessment: sharing assessment findings. 4. R stands for Recommendation: suggesting actions. 5. E stands for Explanation: clarifying any questions. This model ensures all necessary information is communicated effectively. A, B, and C are incorrect because attending hand-off rounds, conducting audits, and creating templates may not ensure standardized communication like the SHARE model does.

Correct Answer: C

Rationale: The correct answer is C because maintaining a nonjudgmental attitude promotes honest communication with the client. This is crucial in building trust and rapport, allowing the client to feel comfortable sharing important information about their health and lifestyle. It lays the foundation for effective care and support. Choice A is not the most important action as quitting smoking, although important, may not be the immediate priority during the initial interview. Choice B, while valuable, is not as crucial as fostering an open and honest relationship with the client. Choice D, although important, may not be the primary focus during the initial meeting and may not promote the necessary trust between the client and nurse.

Correct Answer: C

Rationale: The correct answer is C because reduced breath sounds after an open lung biopsy could indicate a potential complication like pneumothorax. In this situation, it is crucial for the nurse to call the physician immediately for further assessment and intervention. This prompt action can help prevent worsening of the client's condition and ensure timely treatment. Choice A is incorrect because applying oxygen and pulse oximetry is not directly addressing the potential complication of reduced breath sounds. Choice B is incorrect because withholding pain medication based solely on a low heart rate is not appropriate without further assessment. Choice D is incorrect because decreasing oxygen flow rate without proper assessment could be harmful if the client is experiencing respiratory distress.