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Anurse wishes to provide client-centered care in all interactions. Which action by the nursebest demonstrates this concept? • Assessesfor cultural influences affecting health care • Ensures that all the clients basic needs are met • Tells the client and family about all upcoming tests • Thoroughly orients the client and family to the room ANS: A Competency in client-focused care is demonstrated when the nursefocuses on communication, culture, respect compassion, client education, and empowerment. By assessing the effect of the clients culture on health care, this nurse is practicing client-focused care. Providing for basic needs does not demonstrate thiscompetence. Simply telling the client about all upcoming tests is not providing empowering education. Orienting the client andfamily to theroom is animportantsafetymeasure,butnotdirectlyrelatedtodemonstratingclientcentered care. DIF: Understanding/Comprehension REF: 3 KEY: Patient-centered care| culture MSC: Integrated Process: Caring NOT: Client Needs Category: Psychosocial Integrity • A nurse is caring for a postoperative client on the surgical unit. The clients blood pressure was 142/76mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse isbest? • Call the Rapid Response Team. • Document and continue to monitor. • Notify the primary care provider. • Repeat blood pressure measurement in 15 minutes. ANS: A The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating before theysuffereitherrespiratoryorcardiacarrest. Sincetheclienthasmanifestedasignificantchange, thenurseshould call the RRT. Changes in blood pressure, mental status, heart rate, and pain are particularly significant. Documentation is vital, but the nursemust do more than document. The primary care provider should be notified, but this is not the priority over calling the RRT. The clients blood pressure should be reassessed frequently, but the priority is getting the rapid care to theclient. DIF: Applying/Application REF: 3 KEY: Rapid Response Team (RRT)| medical emergencies MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation • A nurse is orienting a new client and family to the inpatient unit. What information does the nurseprovide to help the client promote his or her own safety? • Encourage the client and family to be active partners. • Have the client monitor hand hygiene in caregivers. • Offer the family the opportunity to stay with the client. • Tell the client to always wear his or her armband. ANS: A Each action could be important for the client or family to perform. However, encouraging the client to be active in his or her health care as a partner is the most critical. The other actions are very limited in scope and do not provide the broad protection that being active and involveddoes
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