Managing Client Care
These are the five rights of delegation.
What are the Right task, right circumstance, right person, right directions/communication, right supervision/evaluation
This National Patient Safety Goal requires using two patient identifiers before care.
What is Identify Clients Correctly?
Documenting “Client appears lazy and uncooperative” violates this documentation principle requiring objective and measurable data.
What is Factual (FACT documentation)?
(Accept: What is objective documentation?)
This learning domain focuses on physical skill performance.
What is the psychomotor domain?
A nurse catches that a client with a similar name is about to receive the wrong IV antibiotic. The medication is stopped before administration and no documentation error occurred.
What is a near miss?
This tool ranks clients from stable to high-risk based on complexity of care tasks.
What is an acuity calculation tool?
This type of infection develops in a client who has a central line.
What is a Central Line Associated Infection (CLABSI)?
When correcting a medication documentation error, this action preserves the legal integrity of the health record.
What is drawing a single line through the error, writing “error,” initialing, and dating it?
Asking a client to demonstrate how to empty a colostomy bag back to the nurse demonstrates this teaching strategy.
What is the teach back method?
(also accepted return demonstration)
A client receives the wrong dose of heparin, but laboratory values remain within therapeutic range and no injury occurs. The event is documented and reported internally.
What is a patient safety event?
This prioritization framework focuses on the concept of the Primary Survey Such as: nurse to will address a client stridoring before a client reporting 6/10 pain.
What is A-Airway, B-Breathing, C-Circulation, D-Disability, E-Exposure
This critical, unexpected adverse event results in severe harm or death.
What is a sentinel event?
A nurse receives a verbal prescription for morphine 2 mg IV. Before administering it, this safety step must occur to prevent medication error.
What is read-back of the order?
This SMART goal component ensures the client has a specific deadline for achieving the outcome.
What is Timed?
A nurse assigns an assistive personnel to assess a client’s new onset of chest pain. This action violates this right of delegation.
What is the right task?
This discharge planning acronym includes discussing medications, warning signs, and follow-up care.
What is IDEAL discharge planning?
This team is who you reach out to in the event of a client experiencing sudden vital sign changes or deteriorating status.
What is the Rapid Response Team (RRT)?
Before teaching a client about anticoagulant therapy, the nurse assesses health literacy, learning environment, and motivation to learn. This represents this step of the teaching process.
What is assessment?
When teaching an older adult with sensory decline, reducing distractions and presenting information in smaller segments addresses this learning need.
What is adaptation to age-related changes?
(Accept: What is accommodating sensory decline?)
A nurse administers a medication but waits two hours to document it. During shift change, another nurse sees no record of the medication in the EHR and administers a second dose to the client. This situation is an example of this documentation error.
What is failure to document in real time?
This documentation format improves time management and clinical prioritization by separating client-reported symptoms, measurable findings, nursing analysis, and planned interventions. Such as:
Chief complaint: “Client states nausea and vomiting after surgery.”
Problem: “Experiencing postoperative nausea/vomiting.”
What is SOAP?
After a client receives the wrong blood type and develops severe complications, this formal investigative process must occur to determine system breakdowns and prevent recurrence.
What is root cause analysis (RCA)?
After documenting at the end of the shift from memory instead of in real time, a nurse increases the risk of this legal and patient safety consequence.
What is documentation error or failure to meet the standard of care?
(Accept: What is increased risk for legal liability?)
Teaching a client how to change a stoma pouch, ensuring they understand why it is necessary, and confirming they can perform the skill correctly integrates these three learning domains.
What are cognitive, affective, and psychomotor domains?
Multiple nurses report feeling afraid to disclose errors due to bullying, unclear reporting procedures, and favoritism. Medication errors increase, and staff turnover rises. Leadership identifies that client safety is being compromised due to failure of this foundational organizational principle.
What is a culture of safety?