CH 17 Implementing

A client is admitted to the mental health center after attempting suicide. Which client concern is the priority for the nurse to manage? A) Low self-esteem B) Lack of support C) Risk of self-harm D) Feelings of not belonging

C

Which nursing action can be categorized as a surveillance or monitoring intervention? A) Providing hygiene B) Administering a paracetamol tablet C) Auscultating of bilateral lung sounds D) Use of therapeutic communication skills

C

A client recovering after an appendectomy is reporting pain. The nurse administers the ordered pain medication and assists the client to splint the incision. What is the nurse's next step in implementing the plan of care? A) Perform additional nonpharmacological pain interventions. B) Instruct the client that pain medication is available at regular intervals. C) Notify the physician that the client has required pain medications. D) Reassess the client to determine the effectiveness of the interventions.

D

A client tells the nurse, "My doctor has told me I have to have a blood transfusion, but I am a Jehovah's Witness and I can't take one." What is the nurse's most appropriate intervention? A) Discuss possible alternatives to a blood transfusion with the physician. B) Discuss the client's refusal with hospital risk managers. C) Discuss the risks and benefits of a blood transfusion with the client. D) Discuss the client's options with other church members.

A

The nurse is assigned a client who had an uneventful colon resection 2 days ago and requires a dressing change. To which nursing team member should the nurse avoid delegating the dressing change? A) Nursing assistant B) A senior nursing student present for clinical C) Licensed practical nurse D) Registered nurse

A

Which are activities the nurse typically performs during the implementation step of the nursing process? Select all that apply. A) Modifying the client plan of care B) Developing client outcomes and goals C) Measuring how well the client has achieved client goals D) Collecting additional client data E) Collecting a database to enable an effective plan of care F) Performing an initial assessment of the client

A and D

Which is the nurse's priority question to consider prior to delegating a task to an unlicensed assistive personnel (UAP)? A) Does this task fall within the scope of a UAP? B) How can I supervise the completion of this task? C) What is the client's condition? D) How can I explain the task to the UAP?

A

The primary purpose of nursing implementation is to: A) Identify a need for collaborative consults. B) Help the client achieve optimal levels of health. C) Implement the critical pathway for the client. D) Improve the client's postoperative status.

B

The nurse is preparing a client for surgery when the client tells the nurse that the client no longer wants to have the surgery. How should the nurse most appropriately respond? A) Ask the client to discuss the decision with family members. B) Review with the client the risks and benefits of surgery. C) Notify the physician of the client's refusal. D) Discuss with the client the reasons for declining surgery.

D

A nurse who is experienced caring only for well babies is assigned to the neonatal intensive care unit (NICU) because of a shortage of nurses in the NICU. The nurse is assigned to an infant on a ventilator who will require blood transfusions during the shift. What is the nurse's most appropriate course of action? A) The nurse should inform the charge nurse that the nurse does not have the experience to properly care for this client. B) The nurse should ask another nurse who was previously assigned to the client for instruction. C) The nurse should request that the blood transfusions be delayed until the next shift. D) The nurse should recognize the necessity of the assignment and provide care to the best of the nurse's ability.

A

The nurse has instructed the client in self-catheterization, but the client is unable to perform a return demonstration. What is the nurse's most appropriate plan of action? A) Teach the content again utilizing the same method. B) Reassess the appropriateness of the method of instruction. C) Revise the plan to include the inclusion of a support group. D) Report the client's inability to learn to the case manager.

B

The nurse is preparing a client to be discharged from the surgical unit following abdominal surgery. Which intervention will the nurse use to ensure the client's adherence to proper wound care techniques? A) Delegate teaching to unlicensed assistive personnel (UAP). B) Include family members or other caregivers in the education. C) Provide a video demonstration of abdominal wound care. D) Document client education prior to discharge from the unit.

B

Which is the priority question for the nurse to consider before implementing a new intervention? A) Will I need someone to assist me? B) Does this treatment make sense for this client? C) What equipment do I need? D) How much experience do I have with this treatment?

B

Which statement best explains why continuing data collection is important? A) It meets current standards of care. B) It enables the nurse to revise the care plan appropriately. C) It is the most efficient use of the nurse's time. D) It is difficult to collect complete data in the initial assessment.

B

The nurse has prepared to educate a client about caring for a new colostomy. When the nurse begins the instruction, the client states, "I am not ready to deal with this now. I am feeling overwhelmed." What is the nurse's most appropriate action? A) Discontinue the education and ask the client for permission to teach a family member. B) Medicate the client for anxiety and continue the education later. C) Continue the education and remind the client that it is essential to learn self-care. D) Discontinue the education and attempt at another time.

D

The nurse is preparing a client with a bowel obstruction for emergency surgery. Which intervention has the highest priority for this client? A) Teach the client about dietary restrictions during recovery. B) Discuss discharge plans with the client. C) Instruct the client and family in wound care. D) Inform the client what to expect after the surgery.

D

The nurse must give instructions before discharge to a 13-year-old in a sickle cell crisis. Three of the client's friends from school are visiting. In order to assure effective instruction, what should the nurse plan to do? A) Delay the instruction until the visitors leave. B) Give the visitors instructions to leave in 10 minutes. C) Leave written information for the client to read later. D) Ask the client if the client has any questions.

A

Which is an independent (nurse-initiated) action? A) Administering medication to a client B) Meeting with other health care professionals to discuss a client C) Helping to allay a client's fears about surgery D) Executing physician orders for a catheter

C

An 87-year-old client has been admitted to the hospital several times in the past few months for exacerbations of chronic obstructive pulmonary disease and elevated blood glucose levels. Which statement by the client could help identify the most likely reason for the changes in the client's health status? A) "I asked my neighbors to help me with my yard work." B) "My wife's been gone for about 7 months now." C) "My daughter has been staying with me the past few weeks." D) "I sort my medication into an organizer every week."

B

One hour after receiving pain medication, a postoperative client reports intense pain. What is the nurse's appropriate first action? A) Consult with the physician for additional pain medication. B) Assess the client to determine the cause of the pain. C) Discuss the frequency of pain medication administration with the client. D) Assist the client to reposition and splint the incision.

B

The surgeon is insisting that a client consent to a hysterectomy. The client refuses to make a decision without the consent of the client's spouse. What is the nurse's best course of action? A) Remind the client that the client is responsible for the client's own health care decisions. B) Ask the client whether the client is afraid that the spouse will be angry. C) Ask the surgeon to wait until the client has had a chance to talk to the spouse. D) Inform the surgeon that the nurse will not sign the informed consent form.

C

Before implementing any planned intervention, which action should the nurse take first? A) Ask the client whether this is a good time to do the intervention. B) Record the planned intervention in the client's medical record. C) Have the required equipment ready for use. D) Reassess the client to determine whether the action is needed.

D

A client is diagnosed with hypertension, placed on a low-sodium diet, and given smoking cessation literature. The nurse observes the client eating from a fast food restaurant bag that a family member brought in and the client states, "I don't think I can do this." What is the nurse's first objective when implementing care for this client? A) Explain the effects of a high-salt diet and smoking on blood pressure. B) Collaborate with other health care professionals about the client's treatment. C) Change the nursing care plan. D) Identify what barriers the client feels are preventing adherence with the plan.

D

A nurse is performing a sterile dressing change on a client's abdominal incision. While establishing the sterile field, the nurse drops the forceps on the floor. The nurse is unable to continue with the dressing change because there are no extra supplies in the room, and no one is present to bring new forceps. The nurse failed to organize: A) Logistics and planning. B) Skills and assistance. C) Environment and client. D) Equipment and personnel.

D

During morning report, the night nurse tells the oncoming nurse that the client has been medicated for pain and is resting comfortably. Thirty minutes later, the client calls and requests pain medication. What is the nurse's appropriate first action? A) Go to the client and assess the client's pain. B) Instruct the client in nonpharmacologic pain management. C) Medicate the client with the ordered pain medication. D) Determine the frequency of pain medication.

A

Before implementing any planned intervention, which action should the nurse take first? A) Have the required equipment ready for use. B) Reassess the client to determine whether the action is needed. C) Record the planned intervention in the client's medical record. D) Ask the client whether this is a good time to do the intervention.

B

Which task would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? A) Retrieve a unit of blood from the blood bank. B) Provide the client with assistance in transferring to the bedside commode. C) Reassess the client's sacrum for redness when doing a bed bath. D) Assess an IV site for possible infiltration

B

The nurse has assessed a client and determined that the client has abnormal breath sounds and low oxygen saturation level. The nurse is performing what type of nursing intervention? A) Collaborative B) Maintenance C) Surveillance D) Supportive

C

The client is having difficulty breathing. The respiratory rate is 44 and the oxygen saturation is 89% (0.89 L). The nurse raises the head of the bed and applies oxygen at 3 L/min per nasal cannula. How does the nurse determine the effectiveness of the interventions? Select all that apply. A) The client states, "I can breathe easier now." B) The client is watching television. C) The client's family asks if the client is going to be okay. D) The client's oxygen saturation level increases. E) The client's respiratory rate decreases.

A, D, and E

The client is in a rehabilitation unit after a traumatic brain injury. In order to facilitate the client's recovery, what would be the nurse's most appropriate intervention? A) Arrange with the nurse case manager for an early discharge. B) Teach the family to anticipate the client's needs to care for the client. C) Encourage the client to provide as much self-care as possible. D) Perform all care activities for the client to facilitate rest.

C

A nurse is providing care to several assigned clients and decides to delegate the task of morning vital signs to unlicensed assistive personnel. The nurse would assume responsibility and refrain from delegating this task for which client? A) A client with a high fever receiving intravenous fluids, antibiotics, and oxygen B) A middle-aged client who had abdominal surgery 3 days ago and is ambulating in the hall C) An adult client who is being treated for kidney stones D) An older adult with pneumonia who is being discharged to the son's home tomorrow

A

Nursing interventions for the client after prostate surgery include assisting the client to ambulate to the bathroom. The nurse concludes that the client no longer requires assistance. What is the nurse's best action? A) Revise the care plan to allow the client to ambulate to the bathroom independently. B) Continue assisting the client to the bathroom to ensure the client's safety. C) Instruct the client's family to assist the client to ambulate to the bathroom. D) Consult with the physical therapist to determine the client's ability.

A

When the nurse enters the room to assess a client's vital signs, the client insists that the nurse perform handwashing. What is the nurse's most appropriate action? A) Praise the client for taking an active role in the client's care. B) Inform the client that it is not necessary to wash hands before vital signs. C) Tell the client that gloves are required for this procedure. D) Reassure the client that the nurse knows when to perform hand hygiene.

A

When the nurse is administering medication, an older adult client states, "Why does everyone keep asking my name? I've been here for days." How should the nurse respond to the client? A) "We ask your name to ensure that we are treating the right client." B) "It is a habit that nurses develop in school." C) "We ask your name to show that we respect your rights." D) "It is a hospital policy to reduce the potential for errors."

A

Which tasks can the nurse appropriately delegate to the unlicensed assistive personnel (UAP)? Select all that apply. A) Record the client's intake and output. B) Assess the client's risk for pressure injuries. C) Assess the client's need for education. D) Assist the client to the bedside commode. E) Administer routine oral medications.

A and D

While auscultating a client's lung sounds, the nurse notes crackles in the left lower lobe, which were not present at the start of the shift. The nurse is engaged in which type of nursing intervention? A) Maintenance B) Surveillance C) Educational D) Psychomotor

B

Which nursing actions reflect the implementing step of the nursing process? Select all that apply. A) Providing health education to reduce health risks B) Using evidence-based interventions individualized for the client C) Selecting culturally sensitive nursing interventions D) Referring the client to community resources, when necessary E) Determining the client's response to nursing interventions

A, B, and D

A client cannot afford the treatment prescribed. Who would be the most appropriate professional for the nurse to involve with the client's care? A) Nurse manager B) Nurse case manager C) Physician D) Insurance company

B

After instituting interventions to increase oxygenation, the client shows no signs of improvement. What is the nurse's priority action? A) Reassess the client for improvement in 30 minutes. B) Communicate with the physician for additional orders. C) Determine the client's code status in case of an emergency. D) Document the interventions and the result.

B

Which actions are examples of nursing actions listed in the ANA's Nursing: Scope and Standards of Practice for Standard 5: Implementation? Select all that apply. A) The nurse develops expected outcomes that provide direction for the continuity of care. B) The nurse documents implementation and any modifications, including changes or omissions, of the identified plan. C) The nurse demonstrates quality by documenting the application of the nursing process in a responsible, accountable, and ethical manner. D) The nurse utilizes community resources and systems to implement the plan. E) The nurse utilizes evidence-based interventions and treatments specific to the diagnosis or problem. F) The nurse incorporates new knowledge to initiate changes in nursing practice if the desired outcomes are not achieved.

B, D, and E

The Joint Commission (TJC) encourages clients to become active, involved, and informed participants on the health care team. What nursing action follows TJC recommendations for improving client safety by encouraging them to speak up? A) The nurse encourages clients to advocate for themselves instead of choosing a trusted family member or friend. B) The nurse assures the client who questions a medication that it is the right medication prescribed for him or her and administers the medicine. C) The nurse encourages the client to participate in all treatment decisions as the center of the health care team. D) The nurse explains each procedure twice to prevent client questions from wasting time.

C

The nurse is coordinating care for a client with continuous pulse oximetry who requires pharyngeal suctioning. To which staff member should the nurse avoid delegating the task of suctioning? A) Licensed practical nurse B) Registered nurse C) Nursing assistant who is a nursing student D) A senior nursing student present for clinical

C

The nurse is discussing diabetes mellitus with the family members of a client recently diagnosed. To promote the health of the family members, what would be the most important information for the nurse to include? A) The cellular metabolism of glucose B) Medications used to treat diabetes mellitus C) Risk factors for and prevention of diabetes mellitus D) The severity of the client's disease

C

A nurse suspects that the client with Crohn's disease does not understand the medication regimen or diet modifications required to manage the illness. What is the nurse's most appropriate action? A) Ask the gastroenterologist to explain the treatment plan to the client and family again. B) Ask the nutritionist to give the client strict meal plans to follow. C) Refer the client to available community resources and support groups. D) Ask the client to verbalize the medication regimen and diet modifications required.

D

The home health nurse caring for a client with limited eyesight notes that the client's route to the bathroom is cluttered. What is the most effective way for the nurse to ensure the client's long-term safety? A) Remove all the cluttered objects from the pathway to the client's bathroom. B) Assign a home health aide to perform housekeeping duties. C) Instruct the client about the need to keep the walkway to the bathroom clear. D) Assist the client to identify strategies to promote safety in the home.

D

The nurse is discussing dietary options with a client who is upset due to not being able to have foods the client previously enjoyed. The nurse states, "You may not be able to have steak, but you can have grilled salmon or grilled chicken. Which do you prefer?" A) What is the purpose for giving the client an option? B) To encourage the client to make a healthy food choice C) To give the client the opportunity to actively participate in care D) To save the client the trouble of looking in the menu E) To help the client adhere to the plan

C

The nurse is preparing to administer a blood pressure medication to a client. To ensure the client's safety, what is the priority action for the nurse to take? A) Ask the client to verbalize the purpose of the medication. B) Tell the client to report any side effects experienced. C) Assess the client's blood pressure to determine if the medication is indicated. D) Determine the client's reaction to the medication in the past.

C

An unlicensed assistive personnel (UAP) has worked on the postpartum unit for many years. The UAP has been oriented well and provides excellent client care. What duties could the professional nurse appropriately delegate to the UAP? Select all that apply. A) Initial assessment of the mother after birth of the infant B) Providing routine discharge instructions related to infant care C) Transporting the infant to the mother's room according to hospital policy D) Assisting the client with personal hygiene needs and ambulation E) Assisting and teaching the client to breastfeed the infant

C and D

As part of a client's plan of care, a nurse teaches a client's spouse how to perform a dressing change to the client's abdominal wound. Which method would be most effective to determine whether the spouse has mastered the skill? A) Spouse lists the signs of healing. B) Spouse performs the steps of the dressing change correctly. C) Spouse identifies the steps for the dressing change. D) Spouse shows the nurse what supplies are needed.

B

The emergency room nurse is performing an initial assessment of a new client who presents with severe dizziness. The client reports a medical history of hypertension, gout, and migraine headaches. Which step should the nurse take first in the comprehensive assessment? A) Discuss the need to change positions slowly, especially when moving from sitting to standing. B) Perform vital signs and blood glucose level. C) Initiate an intravenous line and administer 500mL of normal saline. D) Perform a full review of systems.

B

The nurse ascertains that a client is failing to follow the plan of care that was collaboratively developed. Further investigation determines that the plan of care is not appropriate for this client. What is the nurse's next step in correcting this problem? A) Discuss the desired outcomes with the client and the importance of the outcomes. B) Make changes in the plan of care based upon assessment data. C) Ask the client's family to assist the client in following the plan of care. D) Provide information to the client on the benefits of complying with the plan of care.

B

The nurse is caring for a 10-year-old client who is newly diagnosed with a seizure disorder. What variable would alter the nurse's plan for educating the client and parent? A) The client expresses a desire to learn how to manage the medication regime. B) The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years. C) The parents have comprehensive insurance coverage for their family's medical care. D) The parents verbalize acceptance of the need to closely monitor their child's condition.

B

The nurse is caring for a client with congestive heart failure. The nurse manager informs the nurse that the client was enrolled in a clinical trial to assess whether a 10-minute walk, 3 times per day, leads to expedited discharge. Which type of evaluation best describes what the researchers are examining? A) Cost-effectiveness B) Outcome C) Process D) Structure

B

Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? A) Preparation of insulin for the diabetic client with an elevated blood glucose level B) Bed bath for the newly admitted client who has multiple skin lesions C) Insertion of a urinary catheter in a client with benign prostatic hypertrophy D) Ambulation of the client with a history of falls for the first time after surgery

B

Which nursing intervention is most likely to be allowed within the parameters of a protocol or standing order? A) Changing a client's advance directive after the prognosis has significantly worsened B) Administering a beta-adrenergic blocker to a new client whose blood pressure is high on admission assessment C) Changing a client's intravenous (IV) fluid from normal saline to 5% dextrose D) Administering a glycerin suppository to a constipated client who has not responded to oral stool softeners

D