An acute care unit RN is managing client assignments alongside a licensed practical nurse (LPN/VN) and an unlicensed assistive personnel (UAP). After concluding a multidisciplinary huddle, the RN receives several simultaneous updates. Arrange the following required actions in order from highest to lowest priority.
- 1Evaluate a client immediately after the UAP reports a new onset of substernal chest pain and profound diaphoresis.
- 2Halt the LPN/VN from initiating an independent dietary teaching plan for a client newly diagnosed with type 1 diabetes mellitus.
- 3Assess the sacral skin integrity of a completely immobile client following a bed bath delegated to the UAP.
- 4Establish clear parameters with the UAP regarding which vital sign abnormalities to report for a clinically stable client awaiting discharge.
Cevap
The correct sequence is: assess the client with chest pain, halt the LPN/VN from teaching, evaluate the skin integrity after the bed bath, and establish vital sign parameters with the UAP.
The correct sequence prioritizes immediate physiological threats, followed by imminent scope of practice violations, routine evaluation of delegated tasks, and finally, communication for stable clients. The client with chest pain has a potentially fatal condition requiring immediate assessment. Next, the RN must stop the LPN/VN from performing initial teaching, as this is solely an RN responsibility. The RN then evaluates the outcome of a delegated task (bed bath) to fulfill the Right Supervision. Finally, the RN provides parameters for a stable discharge client, which fulfills the Right Direction but is not immediately time-sensitive.
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Anahtar Kavram
Prioritization of care must integrate the ABCs of physiological stability with the Five Rights of Delegation and strict adherence to the nursing scope of practice.