A nurse is working with an RN to admit a new client. Which of the following steps of the nursing process is the nurse using when assisting to formulate goals for a positive outcome?

Choice A reason: A sentinel event is a serious adverse event that results in death, permanent harm, or severe temporary harm to a patient. Administering incompatible blood products to a client is a sentinel event because it can cause fatal hemolytic reactions.

Choice B reason: Administering client medications 30 minutes late is not a sentinel event, unless it leads to a serious adverse outcome for the patient. Medication errors are common and preventable, and they should be reported and analyzed to improve patient safety.

Choice C reason: Documenting vital signs at the wrong time in the client’s electronic health record is not a sentinel event, unless it leads to a serious adverse outcome for the patient. Documentation errors are also common and preventable, and they should be corrected and avoided to ensure accurate and timely information.

Choice D reason: Administering a prescribed sedative to a client for insomnia is not a sentinel event, unless it leads to a serious adverse outcome for the patient. Sedatives are commonly used to treat insomnia, and they should be prescribed and administered with caution and monitoring⁵.

Choice A reason: There are not 4 rights of delegation, but 5 rights of delegation. The 5 rights of delegation are the right task, the right circumstance, the right person, the right direction or communication, and the right supervision or evaluation. The nurse should know and apply these rights when delegating tasks to other members of the health care team.
Choice B reason: The nurse manager is not the only one responsible for delegating nursing tasks during each shift, but the registered nurse (RN) is also responsible for delegating nursing tasks within their scope of practice. The RN should delegate tasks based on the client's needs, the staff's competencies, and the organizational policies. The nurse manager should support and oversee the delegation process, but not assume the sole responsibility for it.
Choice C reason: It is not the duty of the delegate to perform a task without asking questions when it is delegated, but to ask questions or clarify any doubts or concerns before accepting or performing the task. The delegate should communicate effectively with the delegator and ensure that they understand the task, the expected outcome, the time frame, and the resources available. The delegate should also report any problems or issues that arise during or after the task completion.
Choice D reason: I am responsible for ensuring that a delegated task is completed is a correct statement that indicates understanding of delegation. The delegator is accountable for the decision to delegate and the outcome of the task. The delegator should monitor and evaluate the performance and the results of the task, and provide feedback and recognition to the delegate. The delegator should also intervene or take corrective actions if needed.