A nurse is assisting with the care of a group of clients. Which of the following actions should the nurse take to manage her time effectively? (Select all that apply.)

Keep track of how long it takes to complete certain tasks.

Delegate collection of vital signs to the assistive personnel on the team.

Make a priority to-do list at the beginning of the shift.

Plan a time at the end of the shift to document nursing interventions.

Complete activities with one client before moving to another client.

Answer and Explanation

Correct Answer : A,B,C,E

A. Keep track of how long it takes to complete certain tasks is correct. Tracking the time it takes to complete tasks can help the nurse identify areas for improvement and prioritize tasks accordingly.

B. Delegate collection of vital signs to the assistive personnel on the team is correct. Delegating tasks such as vital sign monitoring to assistive personnel allows the nurse to focus on higher-level clinical duties and improves time management.

C. Make a priority to-do list at the beginning of the shift is correct. Creating a to-do list helps the nurse organize tasks based on urgency, improving overall time management and ensuring critical tasks are addressed.

D. Plan a time at the end of the shift to document nursing interventions is incorrect. Documentation should be done throughout the shift as interventions are performed, not solely at the end. Delaying documentation can lead to errors and missed information.

E. Complete activities with one client before moving to another client is correct. Focusing on one client at a time helps ensure each task is completed thoroughly and reduces the risk of neglecting important care steps.

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Correct Answer is D

Explanation

A. "Count the client's respirations for 15 seconds" is incorrect. The nurse should count respirations for a full 60 seconds to ensure accuracy, especially in postoperative clients, as irregularities may be more easily detected with a longer observation period.

B. "Place the client in a supine position" is not necessary. While the position of the client can affect respiration, the nurse does not need to place the client in a supine position specifically to assess respirations. The client should be in a comfortable position that allows for adequate observation.

C. "Inform the client when beginning to observe his respirations" is incorrect. The client should not be aware that their respirations are being counted, as awareness can alter their breathing patterns and lead to inaccurate data.

D. "Observe the movements of the client's chest wall" is correct. Observing the chest wall allows the nurse to assess the rate, depth, and rhythm of respirations, as well as any signs of distress or abnormal patterns, which is crucial for monitoring postoperative respiratory status.

A. Measure the duration of the seizure. B. Lower the side rails of the bed when the seizure begins. C. Insert an oral airway into the client's mouth. D. Restrain the client's arms and legs to prevent injury.

Correct Answer is A

Explanation

A. Measure the duration of the seizure. This is the correct action. Monitoring the duration of the seizure is important for assessing its severity and deciding when to intervene medically. A seizure lasting longer than 5 minutes requires immediate intervention.

B. Lower the side rails of the bed when the seizure begins. This is not recommended. The side rails should be raised to protect the client from injury. Lowering them could increase the risk of falling out of bed.

C. Insert an oral airway into the client's mouth. This is incorrect. Inserting an airway into the mouth during a seizure can be dangerous and may result in injury to the client or the nurse. The client’s airway should be kept clear, but inserting an object into the mouth is not recommended.

D. Restrain the client's arms and legs to prevent injury. This is incorrect. Restraining the client during a seizure can cause injury to both the client and the nurse. It is better to allow the seizure to proceed naturally while ensuring the client is protected from injury (e.g., by placing a soft pillow under their head or cushioning hard surfaces around them).

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A nurse is assisting with the care of a group of clients. Which of the following actions should the nurse take to manage her time effectively? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who is postoperative. Which of the following actions should the nurse take when collecting data about the client's respirations?

Correct Answer is D

Explanation

A nurse is caring for a client who is in bed and begins experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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