A nurse is receiving change-of-shift report at the start of the shift. Which of the following statements by the nurse giving report indicates to the oncoming nurse that she should assume total care for the client, rather than assigning tasks to the assistive personnel (AP)?

"The client works in the hospital radiology department."

"The client discussed having prior thoughts of suicide."

"The client's blood pressure and pulse have been fluctuating throughout the day."

"The client's family members have been present most of the day."

Answer and Explanation

The Correct Answer is C

A. "The client works in the hospital radiology department": This information is irrelevant to the client’s current health status and does not imply a need for total care by the nurse.

B. "The client discussed having prior thoughts of suicide": While suicidal ideation is serious and requires careful monitoring and assessment, this information alone does not necessarily indicate that the nurse must assume total care. A nurse would still delegate non-critical tasks to the AP, but constant monitoring and appropriate interventions would still be the nurse’s responsibility.

C. "The client's blood pressure and pulse have been fluctuating throughout the day": Fluctuating vital signs, especially blood pressure and pulse, can indicate an unstable condition that may require immediate attention and careful monitoring. This scenario suggests that the client’s condition may be critical and requires ongoing assessment and evaluation by the nurse, rather than simply delegating tasks like monitoring vital signs to assistive personnel (AP). The nurse needs to assess the situation thoroughly, interpret the fluctuations, and adjust the care plan accordingly.

D. "The client's family members have been present most of the day": Family presence alone does not impact the need for total care by the nurse. It is important for the nurse to communicate with the family, but this statement does not indicate the need for the nurse to assume total care over other team members.

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Correct Answer is D

Explanation

A. Reassign the task to another nurse: While reassignment may be an option, it does not address the underlying issue. Ensuring the LPN has the knowledge and skill to complete the task is more effective in addressing both immediate and future concerns.

B. Report the issue to the unit manager: Reporting to the manager might be appropriate if the issue persists or reflects repeated non-compliance. However, verifying the LPN's competence and addressing the problem directly should be the first step.

C. Change the client’s dressing: While changing the dressing resolves the immediate client need, it does not address the issue of delegation or why the task was not completed. This approach bypasses the opportunity to assess and support the LPN.

D. Verify the LPN knows how to do a dressing change: Before taking further action, the charge nurse should determine why the task was not completed. If the LPN lacks the knowledge or skill to perform a dressing change, the nurse must address this gap and provide appropriate education or support to ensure client care is not compromised.

A. "What do you have against me? It must be something or you wouldn't be criticizing my care." B. "You shouldn't make accusations. Your nursing care doesn't always set a good example." C. "I feel as though I met the standard of care. Would you tell me more about your concerns?" D. "I am at a loss for words. I always do my best to give good care to my clients."

Correct Answer is C

Explanation

Rationale:

A. "What do you have against me? It must be something or you wouldn't be criticizing my care." is defensive and confrontational, which is not appropriate for assertive communication.

B. "You shouldn't make accusations. Your nursing care doesn't always set a good example." is also defensive and shifts the focus away from addressing the concern directly.

C. "I feel as though I met the standard of care. Would you tell me more about your concerns?" is an assertive response that acknowledges the concern and seeks constructive feedback.

D. "I am at a loss for words. I always do my best to give good care to my clients." is not assertive as it does not address the concern directly or invite constructive discussion.

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A nurse is receiving change-of-shift report at the start of the shift. Which of the following statements by the nurse giving report indicates to the oncoming nurse that she should assume total care for the client, rather than assigning tasks to the assistive personnel (AP)?

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