2023 VATI Assessment Leadership Rationales

Document Content and Description Below

VATI Assessment Leadership Rationales 4. Inform the provider to ask the grandfather to provide consent. The nurse should inform the provider that the grandfather is the closest adult relative avail... able for signing the informed consent in this emergency situation when parents are not available. Obtain consent from the client. MY ANSWER The client, who is a minor, cannot legally sign an informed consent form for surgery unless the minor is emancipated (living on his own, lawfully married, or serving in the military). Find out whom the client has named as his health care proxy. A health care proxy is an individual designated by an adult client in a durable power of attorney document to make health care decisions when the client is incapacitated. Proceed with the surgery via implied consent. Implied consent is appropriate in an emergency when a client is unable to sign, or is a minor, due to unconsciousness or in a life-threatening emergency, and there is no one available to give informed consent legally. 7. Returning the client to the wrong room after surgery Returning the client to the wrong room after surgery needs to be resolved; however, this does not place the client at risk and does not require completion of an incident report. This situation is identified as a near miss because the client was not injured and no property was damaged. Delivering diet trays to the wrong clients Delivering diet trays to the wrong clients requires correction of the error before the clients eat; however, this does not place clients at risk and does not require completion of an incident report. This situation is identified as a near miss because the client was not injured and no property was damaged. Discovering an incorrect insulin dosage recorded on the medication administration record MY ANSWER Discovering an incorrect insulin dosage recorded on the medication administration record requires a correction to be made; however, this does not place the client at risk and does not require completion of an incident report. This situation is identified as a near miss because the client was not injured and no property was damaged. Losing a client's dentures Losing a client's dentures requires an incident report to be completed. In this situation, the client's personal property was lost and requires the creation of an incident report to track the progress of the occurrence. Primary nursing Primary nursing is a form of total client care in which one nurse has 24-hr responsibility and accountability for the nursing care of specific clients for the duration of their stay at the facility to promote clear communication among the health care team. Team nursing Team nursing is the most common nursing care delivery system. The nurse manager divides the nursing staff into teams, including staff of various skills and licensure. Each team provides total care to a specific group of clients and has a team leader. Functional nursing MY ANSWER Functional nursing, also called task nursing, involves the nurse manager breaking down the needs of the clients into tasks and assigning the tasks using the skill and licensure of each staff member appropriately and efficiently. This model of nursing is uncommon in acute care settings, except in crisis situations, or when there is a shortage in staffing numbers. Modular nursing Modular nursing is a type of team nursing in which a manager assigns a team of staff of various skills and licensure to a given geographic area (or module), often called care pairs. An example of modular nursing is assigning a team to a group of clients' rooms. 12. Apply moisturizing lotion to the client's skin after bathing. The client who has dry and irritated skin is at a greater risk for skin breakdown and the development of a pressure ulcer. The nurse should minimize dryness by applying moisturizing lotions while the client's skin is moist after bathing. Massage the client's bony prominences twice per shift. MY ANSWER The nurse should avoid massaging bony prominences. Evidence-based practice does not support this intervention and vigorous massage can lead to deep tissue trauma. Maintain the head of the client's bed at a 45° angle. The nurse should elevate the head of the client's bed to no more than 30° when the client is in a lateral position to reduce injury occurring from friction and shearing forces. Place the client in contact isolation. The client who is at risk for developing a pressure ulcer does not require contact precautions. The nurse and personnel caring for the client should follow standard precautions to prevent infection and pathogen transmission. 14. The client was medicated with morphine 2 mg IV 1 hr ago. This information provides medical information that is pertinent to the client's condition and is part of the background portion (B) of the SBAR communication tool. The client needs a change in pain medication prescription. MY ANSWER This information provides a potential solution for the client's current need and is part of the recommendation portion (R) of the SBAR communication tool. The client is reporting a pain level of 8 on a scale from 0 to 10. This information provides a brief explanation of the current situation and is part of the situation portion (S) of the SBAR communication tool. The client has a heart rate of 110/min and a BP of 148/88 mm Hg. This information provides recent assessment data indicating the client's current condition and is part of the assessment portion (A) of the SBAR communication tool. Recognize individual efforts during the change process. The nurse manager should recognize individual efforts during the change process to increase driving forces to promote the change; however, there is another action the nurse should take first. Develop strategies to enhance acceptance of changes. The nurse manager should develop strategies to enhance acceptance of changes to improve the understanding of the changes; however, there is another action the nurse should take first. Create a task force to implement needed changes. The nurse manager should create a task force to implement needed changes to promote an increased acceptance of the changes; however, there is another action the nurse should take first. Determine the unit staff's perception of the need for change. MY ANSWER The first action the nurse should take when using the nursing process is assessment. By determining the unit staff's perception of the need for change, the nurse manger will be able to implement effective change. 17. "I need to choose a family member to be my health care proxy." The client can designate any competent person to be a health care proxy. A health care proxy does not have to be a family member. "My family member or a friend will use my living will for health care decisions when I am ill." MY ANSWER The client's living will authorizes a designated health care proxy or the client's provider to use the living will for health care decisions when the client is no longer able to make decisions regarding treatment. "I am unable to change my living will after I have signed it." The client can change a living will at any time, even after signing it. "My health care proxy will make my health care decisions when I am no longer able." The nurse should identify the health care proxy can make health care decisions for the client if the client is no [Show More]

Last updated: 1 year ago

Preview 1 out of 13 pages