A nurse is caring for a 2-year-old child who has Clostridium difficile. Which of the following actions should the nurse take?

Rationale:

A. Plan a time at the end of the shift to document nursing interventions: Delaying documentation until the end of the shift risks forgetting important details and compromises accuracy. Best practice is to document interventions and observations as close to the time of care as possible to ensure timely, complete records.

B. Delegate collection of vital signs to the assistive personnel on the team: Delegating routine tasks like vital sign collection allows the nurse to focus on complex responsibilities requiring clinical judgment. This supports time efficiency while ensuring client care needs are still met promptly.

C. Make a priority to-do list at the beginning of the shift: Creating a task list based on client acuity and scheduled interventions helps the nurse remain focused and organized. Prioritizing tasks early supports decision-making and improves workflow throughout the shift.

D. Keep track of how long it takes to complete certain tasks: Monitoring time spent on different tasks helps identify inefficiencies and allows the nurse to adjust workflow. This self-awareness supports better time management in future shifts.

E. Complete activities with one client before moving to another client: Focusing on one client at a time may lead to inefficiencies and delayed care for other clients. Nurses should cluster care and prioritize based on client needs, rather than adhering rigidly to completing all care for one client before moving on.

Rationale:

• Contact the provider for an antibiotic prescription: Contacting the provider ensures the client receives prompt intervention for a likely surgical site infection. The wound is inflamed and draining yellow pus, and the client has a fever and leukocytosis. Early treatment can prevent the progression to severe sepsis.

• Increase the volume on the television: Increasing the volume on the television can heighten sensory overload and worsen the client’s confusion. Delirium management involves reducing noise and visual stimuli, not adding to it. This approach does not promote orientation or calmness.

• Ask the client's partner to leave the room: Asking the client's partner to leave may remove a critical source of comfort and familiarity. Familiar people help reorient clients with delirium or confusion. Their presence often reduces agitation and promotes emotional security.

• Dim the lights: Dimming the lights reduces environmental overstimulation that may worsen delirium. The client is experiencing hallucinations and disorientation, which are often intensified in bright ICU settings. A calm setting supports cognitive clarity and comfort.

• Assist with elimination: Assisting with elimination is appropriate if the client shows signs of distress or discomfort. However, this need is not emergent compared to infection and altered mental status. Treating the underlying cause of delirium should take precedence.

• Place the client in 4-point restraints: Placing the client in 4-point restraints is a last resort when other safety measures fail. Restraints can escalate agitation and lead to injury or trauma. Delirium should be managed first with environmental and medical interventions.