Management of Care 2 — Questions and Answers

Question 1: A nurse is caring for four clients. Which client should the nurse assess first?

A post-operative client reporting pain of 6/10 following knee replacement
A client with COPD whose oxygen saturation has dropped from 94% to 88% (Correct answer)
A client requesting assistance to the bathroom
A client awaiting discharge teaching for diabetes management

Correct answer: A client with COPD whose oxygen saturation has dropped from 94% to 88%

A drop in oxygen saturation to 88% in a COPD client represents an acute change in respiratory status and a potential airway/breathing emergency. This takes priority over the other clients using the ABCs (Airway, Breathing, Circulation) framework.

Prioritization is a critical nursing management skill. The ABCs framework (Airway, Breathing, Circulation) guides initial triage: life-threatening problems affecting breathing or oxygenation are always addressed first. An acute drop in oxygen saturation from 94% to 88% represents a significant change in respiratory status that could indicate worsening hypoxia, bronchospasm, mucus plugging, or acute exacerbation of COPD. In COPD patients, the hypoxic drive theory has been largely updated — current evidence does not support withholding oxygen to avoid respiratory depression in most acute situations, but significant desaturation still requires immediate assessment and intervention. The nurse should assess the client's respiratory effort, auscultate breath sounds, review current medications, and implement ordered interventions (oxygen titration, bronchodilators) or notify the provider urgently. The client with pain of 6/10 is uncomfortable but not in immediate physiological danger. The client requesting bathroom assistance has a safety concern (fall risk) but can wait briefly or be delegated to a UAP. Discharge teaching is elective and can be deferred without immediate harm. Using maslow's hierarchy alongside ABC prioritization: physiological survival needs (oxygenation) are the highest priority. When multiple physiological concerns exist simultaneously, the nurse must triage based on acuity and immediacy of threat.

Question 2: A nurse is the charge nurse on a medical-surgical unit. A client's family member complains that they have been waiting 2 hours to speak with the physician. Which action is most appropriate?

Instruct the family member to call the physician's office directly
Contact the physician to communicate the family's request for an update (Correct answer)
Tell the family that physicians are very busy and delays are expected
Ask the primary nurse to spend 30 minutes educating the family

Correct answer: Contact the physician to communicate the family's request for an update

The charge nurse should advocate for the client and family by contacting the physician to relay the request for communication. This is part of the charge nurse's advocacy and coordination role and addresses the family's legitimate concern.

Client and family satisfaction is an important component of quality care, and communication between the healthcare team and families is a fundamental right. A 2-hour wait for physician communication without acknowledgment represents a breakdown in care coordination. The charge nurse serves as a resource, advocate, and coordinator on the unit. The appropriate action is to contact the physician (via phone, pager, or the facility's communication system) to relay that the family has been waiting and to request a communication update. The nurse documents this communication. Instructing the family to call the physician directly is inappropriate — families should not be redirected to navigate the system independently, and inpatient physicians typically cannot receive direct family calls through standard channels. Dismissing the complaint by normalizing delays is dismissive and does not address the concern. Having the primary nurse spend 30 minutes with the family is potentially helpful but does not address the family's specific request to speak with the physician. Effective charge nursing includes proactive communication management, rounding on families, and ensuring that family questions are routed to the appropriate provider promptly. When physicians are unavailable, the charge nurse may escalate to the supervising physician or resident.

Question 3: A nurse is caring for a client with a new diagnosis of terminal cancer who has just been told their prognosis. The client says, 'I think there's been a mistake. The tests must be wrong.' Which stage of the Kübler-Ross grief model does this represent?

Anger
Bargaining
Denial (Correct answer)
Depression

Correct answer: Denial

Denial is the first stage of the Kübler-Ross grief model and involves refusing to accept the reality of a diagnosis or prognosis. Statements such as 'there must be a mistake' or 'the tests are wrong' are classic expressions of denial.

The Kübler-Ross model describes five stages of grief that individuals may experience when facing terminal illness or significant loss: Denial, Anger, Bargaining, Depression, and Acceptance (DABDA). These stages do not necessarily occur in order, may overlap, and individuals may revisit stages multiple times. Denial serves as a psychological buffer against the overwhelming emotional impact of devastating news. Statements like 'There must be a mistake,' 'The tests must be wrong,' or 'The doctor doesn't know what they're talking about' are typical expressions of denial. This stage is a normal and adaptive coping mechanism that allows the person to absorb the reality gradually. Anger is often expressed as resentment, frustration, or rage directed at providers, family, or even God ('Why me?'). Bargaining involves making deals, often with God, to change the outcome ('If I do everything right, maybe I'll be the exception'). Depression is characterized by profound sadness, withdrawal, and grief over losses. Acceptance is a state of peace with one's situation, not necessarily happiness. The nurse's therapeutic response to denial is not to confront or correct the client, but to offer empathetic presence, maintain hope within the context of realistic goals, and support the client through the grieving process at their own pace.

Question 4: A nurse is caring for a client who speaks limited English. An interpreter is needed for informed consent for a surgical procedure. Which action is most appropriate?

Ask the client's bilingual family member to interpret
Use a picture board to explain the procedure
Utilize a professional medical interpreter (in-person or telephonic) (Correct answer)
Request a bilingual staff member who works on the unit to interpret

Correct answer: Utilize a professional medical interpreter (in-person or telephonic)

A professional medical interpreter (certified) is the most appropriate resource for informed consent communication. Professional interpreters are trained in medical terminology, confidentiality, and neutral interpretation, which is required for valid informed consent.

Providing care to clients with limited English proficiency (LEP) is a significant challenge that directly affects patient safety, quality of care, and informed consent. Title VI of the Civil Rights Act requires healthcare facilities receiving federal funding to provide meaningful access to care for clients with LEP, which includes providing qualified interpreter services at no cost to the client. For high-stakes communications such as informed consent, diagnosis disclosure, discharge planning, and care plan discussions, a professional medical interpreter — certified in medical interpreting — is required. These interpreters are trained to interpret accurately and completely without omitting, summarizing, or editorializing, and are bound by confidentiality. Using family members as interpreters is problematic for several reasons: they may lack medical vocabulary, they may filter or soften information to protect the patient, power dynamics within families can affect what is communicated, and clients may not disclose sensitive information honestly in front of family. Family interpretation is particularly inappropriate for informed consent. Bilingual staff who are not certified interpreters may make interpretation errors due to lack of training. Picture boards are useful supplemental tools but insufficient for obtaining informed consent. Many facilities use telephone or video interpretation services (such as Language Line or Stratus Video) when in-person interpreters are not immediately available.

Question 5: A nurse is preparing a client for discharge. The client will be taking multiple medications at home. Which action best ensures medication safety at discharge?

Provide the client with a written list of all medications with names and dosages only
Instruct the client to consult their pharmacist if they have questions
Conduct teach-back by having the client explain each medication's purpose, dose, and schedule (Correct answer)
Ensure the client signs the discharge medication reconciliation form

Correct answer: Conduct teach-back by having the client explain each medication's purpose, dose, and schedule

Teach-back — having the client explain in their own words the medications' purpose, dose, and schedule — is the gold standard for verifying health literacy and ensuring the client truly understands their discharge regimen.

Medication errors after discharge are a leading cause of preventable hospital readmissions and adverse drug events. Effective discharge education is a key nursing intervention to ensure medication safety and reduce post-discharge complications. The teach-back method (also called 'closing the loop') involves asking the client to restate or demonstrate in their own words what they have been taught. Rather than asking 'Do you understand?' (which typically elicits a 'yes' regardless of comprehension), the nurse asks open-ended questions such as 'Can you show me how you would take your medications each day?' or 'What would you do if you missed a dose of your blood pressure medicine?' If the client's teach-back reveals misunderstanding, the nurse re-teaches using different language or a different approach, then conducts teach-back again. This cycle continues until the client can accurately recall and explain the information. Providing a written medication list is helpful as a reference tool but does not verify understanding. Referring to the pharmacist deflects responsibility and assumes the client will follow up. Signing a form demonstrates consent but not comprehension. Research shows teach-back reduces hospital readmissions and improves medication adherence significantly.

Question 6: A nurse identifies that a colleague has been administering a medication without checking the client's armband for identification. Which action is most appropriate?

Report the colleague to the nursing board immediately
Ignore the behavior since no harm has occurred yet
Approach the colleague privately and address the safety concern (Correct answer)
Document the observation in the client's medical record

Correct answer: Approach the colleague privately and address the safety concern

The most appropriate initial action is to approach the colleague privately and address the safety concern professionally. This is a patient safety issue that requires peer intervention, which is part of a culture of safety.

Patient identification using two identifiers (typically name and date of birth, or name and medical record number) before medication administration is a critical patient safety step required by The Joint Commission. Skipping this step creates the risk of wrong-patient medication errors, which can be fatal. In a culture of safety, nurses are expected to speak up when they observe unsafe practices — this is a professional and ethical responsibility. The most appropriate first step is to approach the colleague privately and respectfully address the observation. Using 'I' statements and focusing on the behavior rather than the person ('I noticed you didn't check the armband before giving that medication — can we talk about that?') is more likely to result in behavior change. Immediate reporting to the nursing board is an extreme step reserved for serious, repeated, or deliberate violations, willful patient harm, or impairment. In this case, the nurse should use the chain of command if direct colleague conversation is ineffective or if the behavior continues. The charge nurse or nursing supervisor may need to be informed if the safety concern persists. Ignoring the behavior is unacceptable — it puts patients at risk and is inconsistent with professional nursing standards. Documenting in the medical record is not appropriate for a peer behavior observation — it belongs in an incident/occurrence report if a near-miss or error occurs.

Management of Care 2

A nurse is caring for four clients.
Which client should the nurse assess first?