A nurse is performing a home safety assessment for a client who has experienced a stroke. Which of the following findings are a safety hazards for them? (Select All that Apply.)

Explanation:

A. Data collection:

Data collection is the initial step of the nursing process where the nurse gathers information about the client's health status, including physical, psychological, social, and environmental factors. This involves conducting assessments, obtaining medical histories, performing physical exams, reviewing diagnostic tests, and gathering information from the client, family members, and other healthcare providers. In the scenario, data collection would involve gathering information about the client's postoperative condition, recovery progress, functional abilities, support system, home environment, and any other relevant factors that would influence the discharge planning process.

B. Evaluation:

Evaluation is the step of the nursing process where the nurse assesses the client's response to interventions, measures progress toward goals, and determines the effectiveness of the care provided. It involves comparing the client's actual outcomes with expected outcomes, identifying any deviations or areas needing improvement, and making adjustments to the care plan as necessary. In the scenario, evaluation would occur after the implementation of the discharge plan to assess the client's readiness for discharge, the achievement of goals, and the overall success of the interventions implemented.

C. Planning:

Planning is the phase of the nursing process where the nurse, in collaboration with the client, family, and healthcare team members, develops a comprehensive plan of care based on the collected data and identified needs. This includes setting priorities, establishing expected outcomes and goals, determining appropriate interventions, creating a timeline for implementation, and coordinating resources and services. In the scenario, planning involves working with the social worker and physical therapist to develop a discharge plan that addresses the client's postoperative needs, ensures continuity of care, promotes recovery, and supports a smooth transition from the healthcare facility to the home or next level of care.

D. Implementation:

Implementation is the phase of the nursing process where the nurse carries out the interventions outlined in the care plan. This involves putting the plan into action, providing direct care, educating the client and family, coordinating services, monitoring progress, and advocating for the client's needs. In the scenario, implementation would occur as the nurse, along with the social worker and physical therapist, initiates the discharge plan, arranges for services and resources, provides education and instructions to the client and family, and ensures that all necessary preparations are made for the client's transition from the hospital.

Explanation:

A. "There are 4 rights of delegation."

This statement is not entirely accurate. Delegation involves several principles, including the right task, right circumstances, right person, right direction/communication, and right supervision/evaluation. Therefore, simply stating "4 rights" does not fully encompass the principles of delegation.

B. “The nurse manager is responsible for delegating nursing tasks during each shift."

This statement is incorrect. While the nurse manager may have oversight and authority regarding delegation policies and procedures, it is typically the responsibility of the delegating nurse (the one assigning tasks) to delegate appropriate tasks to qualified individuals based on their competency and scope of practice.

C. "It is the duty of the delegatee to perform a task without asking questions when it is delegated."

This statement is not accurate and could lead to misunderstandings or errors. Effective delegation involves clear communication, which includes the opportunity for the delegatee to ask questions if they are unsure about any aspect of the delegated task. Encouraging questions helps ensure that the task is understood and performed safely and appropriately.

D. “I am responsible for ensuring that a delegated task is completed."

This statement demonstrates understanding of delegation principles. The delegating nurse (the one assigning tasks) is indeed responsible for ensuring that delegated tasks are appropriate, communicated effectively, and completed according to established standards. This includes providing necessary guidance, supervision, and follow-up to ensure task completion and quality of care.