A nurse is assisting in the care of a client who is on isolation for an infection with vancomycin-resistant enterococcus (VRE). Which of the following actions should the nurse take to prevent the spread of infection?

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. Ask the client to identify what made them upset: The first action should be to assess and de-escalate the situation using therapeutic communication. Asking the client to verbalize their feelings can help reduce agitation, promote self-awareness, and prevent escalation.

B. Assist the client with understanding their needs: Helping the client understand their needs is important but comes after first addressing and calming their immediate emotional agitation through assessment and supportive conversation.

C. Place the client in seclusion: Seclusion is a last-resort intervention when the client poses a danger to themselves or others and less restrictive measures have failed. It should not be the first action without attempting de-escalation techniques.

D. Administer lorazepam IM: Administering medication is appropriate if non-pharmacological interventions fail. However, medication should not be the first response before attempting verbal de-escalation strategies in an agitated client.