VATI Assessment Leadership Rationales
4. Inform the provider to ask the grandfather to provide consent.
The nurse should inform the provider that the
... [Show More] grandfather is the closest adult relative
available 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 Less]