Chapter 17: Implementing

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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?

"We ask your name to ensure that we are treating the right client."

The nurse has assisted the client to ambulate for the first time. After returning the client to bed, what is the nurse's priority intervention?

Assess the client's response to the ambulation.

The nurse is caring for a client who is recovering from a cerebrovascular accident (CVA). When reviewing the client's orders, the nurse notes that one of the physicians wrote orders to ambulate the client while another physician ordered strict bed rest for the client. How would the nurse most appropriately remedy this conflict?

Communicate with the physicians to coordinate their orders.

The mother of a pediatric client being discharged confides to the nurse that her husband is abusive and she is afraid to return home. What is the nurse's most appropriate action?

Coordinate with the case manager to make a safe discharge plan.

A client has a nursing diagnosis of Possible Spiritual Distress. What is the most appropriate nursing intervention?

Discuss spirituality with the client.

The nurse is preparing a client for surgery when the client tells the nurse that he no longer wants to have the surgery. How should the nurse most appropriately respond?

Discuss with the client the reasons for declining surgery.

Nurses perform many independent nursing actions when caring for patients. Which action is considered an independent (nurse-initiated) action?

Helping to allay a patient's fears about surgery

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?

Nursing assistant The nurse should avoid delegating the dressing change to the nursing assistant. The dressing change would be within the scope of practice of the registered nurse, licensed practical nurse, and the senior nursing student.

A client with hypertension being seen for follow-up care has a blood pressure of 160/100. The client reports following the treatment regimen closely and that blood pressure readings have been elevated for the last 2 weeks. What is the nurse's most appropriate action?

Report the findings to the physician for further plans.

A nurse who is experienced caring only for well babies is assigned to the newborn intensive care nursery (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?

The nurse should inform the charge nurse that she does not have the experience to properly care for this client.

Priority setting is based on the information obtained during reassessment and is used to rank nursing diagnoses. Each factor contributes to priority setting except which? • Time and resources • The client's condition • Finances of the client • Feedback from the family

Correct response: • Finances of the client Explanation: The client's condition, time and resources, and feedback or input from the family are all of great value when the nurse is prioritizing the client's nursing diagnoses. The client's finances, however, should not influence the nurse's priority setting. The nursing code of ethics states that clients should receive the same treatment regardless of their ability to pay.

The nurse is planning instruction on wound care to an adult client. What variables would cause the nurse to alter the education plan? Select all that apply.

The client denies the need for education. The client is blind. The client's blindness will require the nurse to alter the education plan to fit the client's needs. The education might also require teaching another person to perform the wound care. If the client denies the need for education, attempting to teach the client at this time will be ineffective. The nurse will need to determine why the client denies the need for teaching and address that issue first. The facts that the client is male, married, and an architect do not have any bearing on the instruction.

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?

Reassess the appropriateness of the method of instruction. It is the nurse's responsibility to revise the plan of care if an intervention is not successful. The most appropriate action of the nurse would be to determine if the initial education was the most effective for this client. Simply teaching the content again without reassessing the client's needs would not necessarily be effective. A support group might be helpful, but not until the client's needs are evaluated. The case manager is not responsible for the client's learning.

The surgeon is insisting that a client consent to a hysterectomy. The client says that she will not make a decision without her husband's consent. What is the nurse's best course of action?

Ask the surgeon to wait until the client has had a chance to talk to her husband.

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 mostappropriate action? • Ask the gastroenterologist to explain the treatment plan to the client and family again. • Ask the client to verbalize the medication regimen and diet modifications required. • Ask the nutritionist to give the client strict meal plans to follow. • Refer the client to available community resources and support groups.

Correct response: • Ask the client to verbalize the medication regimen and diet modifications required. Explanation: If the nurse suspects a client does not understand instructions, the first step is to assess the client's understanding. The most effective way to do that is to have the client repeat the client's understanding of the instructions. The other steps might be interventions that the nurse would institute after determining the client's needs.

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

Correct response: • Does this task fall within the scope of a UAP? Explanation: All of these questions are important, but the priority is whether the task falls within the scope of a UAP. If the answer is no, the rest of the questions are not necessary.

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?

Discuss possible alternatives to a blood transfusion with the physician.

Revise the care plan to allow the client to ambulate to the bathroom independently.

Which nursing action can be categorized as a surveillance or monitoring intervention?

auscultating of bilateral lung sounds

Coordinate with the other disciplines to schedule the tests with adequate rest for the client.

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? • Tell the client to report any side effects experienced. • Ask the client to verbalize the purpose of the medication. • Assess the client's blood pressure to determine if the medication is indicated. • Determine the client's reaction to the medication in the past

Correct response: • Assess the client's blood pressure to determine if the medication is indicated. Explanation: Before initiating any intervention, the nurse must determine if the intervention is still necessary. Before administering blood pressure medication, the blood pressure must be assessed. The client's reaction to the medication previously does not indicate if the medication is indicated at this time. The client's ability to verbalize the purpose of the medication is important to promote self-care, but it is not important for the client's safety at this time. The client's report of side effects would indicate an adverse reaction after the medication is administered, but it would not protect the client's safety before the medication is given.

A client admitted with a wound infection has a temperature of 102.1°F. The nurse administers ordered acetaminophen. How does the nurse plan to reassess the effectiveness of the medication?

Reassess the client's temperature in 1 hour.

The nurse is assessing a client with a diagnosis of hypertension. The client's blood pressure is 178/88 mm Hg, an increase from 134/78 mm Hg at the previous clinic visit. The nurse asks the client what has changed from the previous visit. Which client statement identifies a potential factor interfering with the plan of care?

"My grandchildren have moved in with us while their parents are going through financial difficulties." Many physical, emotional, social, and environmental factors can affect the client's health status and self-care behaviors. In this case, having the grandchildren move in due to financial hardships can be stressful, which would raise the client's blood pressure. Having new healthy cooking techniques, walking more (even if it is uphill and difficult), and home monitoring of blood pressure are all health-promoting activities, which should help to lower blood pressure.

Which nursing action can be categorized as a surveillance or monitoring intervention?

Auscultating of bilateral lung sounds Surveillance or monitoring nursing interventions include detecting changes from baseline data and recognizing abnormal responses. Nurses rely on the senses to detect changes: observing the appearance and characteristics of clients; hearing by auscultation, pitch, and tone; detecting odors and comparing them with past experience and knowledge of specific problems; and using touch to assess body temperature, skin condition, clamminess, or diaphoresis. Nurses use all of these surveillance or monitoring activities to determine the current status of clients and changes from previous states. Nurses often detect subtle changes in a client's condition and communicate them to the physician to minimize problems. Providing hygiene and administering a paracetamol tablet are examples of maintenance nursing interventions. Use of therapeutic communication skills is an example of a supportive nursing intervention.

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? • Reassess the appropriateness of the method of instruction. • Revise the plan to include the inclusion of a support group. • Report the client's inability to learn to the case manager. • Teach the content again utilizing the same method.

Correct response: • Reassess the appropriateness of the method of instruction. Explanation: It is the nurse's responsibility to revise the plan of care if an intervention is not successful. The most appropriate action of the nurse would be to determine if the initial education was the most effective for this client. Simply teaching the content again without reassessing the client's needs would not necessarily be effective. A support group might be helpful, but not until the client's needs are evaluated. The case manager is not responsible for the client's learning.

While observing a new nurse inserting an indwelling urinary catheter, the preceptor observes a break in sterile technique. What is the preceptor's first action? • Report the new nurse's error to the nurse manager for corrective action. • Tell the new nurse that a break in sterile technique has occurred and the procedure must be stopped. • Assign the new nurse to view videos on sterile catheter insertion. • Allow the new nurse to continue with the insertion and discuss the error later away from the client.

Correct response: • Tell the new nurse that a break in sterile technique has occurred and the procedure must be stopped. Explanation: The most important priority is to ensure the client's safety. Because the new nurse has contaminated the sterile field, the risk of introducing infection is high. The procedure must be discontinued. Because the preceptor is working with the new nurse, it would not be necessary to report the new nurse's error to the nurse manager unless it became a pattern of behavior. Assigning the nurse to watch instructional videos might be appropriate, but after the client care issue is resolved.

Nurses use the Nursing Outcomes Classification when choosing nursing goals for clients. What are the goals of the research that is behind the Nursing Outcomes Classification (NOC)? Select all that apply.

To evaluate the validity and usefulness of the classification in clinical field testing To identify, label, and validate nursing-sensitive client outcomes and indicators To define and test measurement procedures for the outcomes and indicators

Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?

bed bath for the newly-admitted client who has multiple skin lesions

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. Process b. Structure c. Outcome d. Cost-effectiveness

c. Outcome Outcome evaluation focuses on measurable changes in the health status of the client or the end results of nursing care, such as an expedited discharge of the client based on the client recovering more quickly due to an intervention. The focus of a process evaluation is the nature and sequence of activities carried out by nurses implementing the nursing process. A structure evaluation or audit focuses on the environment in which care is provided. Cost-effectiveness is not a type of evaluation identified by the American Nurses Association.

In order to successfully implement the plan of care, what parties are essential for the nurse to include?

client, family, and physician

standing orders

document that details the nursing care to be implemented in specific nursing situations, frequently when a physician is not present; may expand scope of nursing responsibilities

The nurse in a Burn Intensive Care Unit (BICU) is caring for a 3-year-old boy who was burned with scalding hot water. He has burns covering 75 percent of his body. His condition is critical but stable. At 1000, the nurse reassesses the client and finds that he is agitated and pulling at his endotracheal tube. What would be the nurse's priority?

ensuring that the endotracheal tube is secure

ensuring that the endotracheal tube is secure ABCs (Airway, Breathing and Circulation) are always top priority in client care

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?

nursing assistant

Coordinator

someone whose task is to see that work goes harmoniously

Implementation of the plan of care is most successful when:

the nurse includes family members and other health care professionals.

direct care

when we are working directly with the patient

A registered nurse (RN) and a licensed practical nurse (LPN) are caring for a client who has been admitted with an acute exacerbation of chronic obstructive pulmonary disease (COPD). Which nursing actions can the RN delegate to the LPN? Select all that apply.

• Obtaining pulse oximetry • Auscultating breath sounds • Administering an oral antibiotic

The client is about to have blood drawn before seeing the health care provider. The spouse while smiling and holding the client's hand, states "Here comes the blood sucker. It is going to hurt bad." This statement is an example of which type of intervention? Select all that apply.

• Psychosocial • Supportive

The client tells the nurse, "I think the nurse last night may have given me the wrong medication, but I was afraid to say anything." What is the nurse's most appropriate response?

"You should always speak up if you have any questions about your care."

Nursing Interventions

Activities that the nurse plans and implements to help the patient achieve identified outcomes

Which nursing intervention is most likely to be allowed within the parameters of a protocol or standing order?

Administering a glycerin suppository to a constipated client who has not responded to oral stool softeners

The nurse is caring for a client admitted to the hospital for renal calculi. What is the action to take first?

Assess for bladder distention.

The nurse is caring for a client admitted to the hospital for renal calculi. What is the action to take first?

Assess for bladder distention. Urinary retention could occur if a kidney stone has become lodged in the urethra. Forcing fluids, straining the urine after each void, and diet as tolerated are appropriate interventions, but these do not address the safety issue of first assessing the bladder for distension, which could potentially cause the client discomfort and harm.

As part of the plan of care, a nurse administers scheduled pain medication to a postoperative client with a pain level of 6 on a 0 to 10 scale. Which action best represents the next step in the nursing process?

Assess pain level in 30 minutes.

One hour after receiving blood pressure medication, the client reports feeling lightheaded and dizzy. What is the nurse's first action?

Assess the client's blood pressure.

Critical Thinking in Implementing

Assess: before any action Reassess: determine the response Revise: as indicated Record:

The nursing is caring for several clients. Which client can the nurse delegate to the unlicensed assistive personnel?

Bathe a client with stable angina who has a continuous IV infusing.

The nursing is caring for several clients. Which intervention can the nurse direct the unlicensed assistive personnel (UAP) to perform?

Bathe a client with stable angina who has a continuous IV infusing.

A client has terminal cancer and the primary care provider has ordered a diagnostic imaging test. The client does not want the test performed so the nurse agrees to dialogue with the primary care provider on the client's behalf. The nurse's actions are what type of intervention?

Coordinating

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 senior nursing student present for clinical • Licensed practical nurse • Registered nurse • Nursing assistant

Correct response: • Nursing assistant Explanation: The nurse should avoid delegating the dressing change to the nursing assistant. The dressing change would be within the scope of practice of the registered nurse, licensed practical nurse, and the senior nursing student.

Delay the instruction until the visitors leave.

The nurse has administered pain medication to a client with a fractured femur. One hour later, the client reports relief of pain. What is the nurse's next action?

Document the effectiveness of the intervention.

Which action is a nursing intervention that facilitates lifespan care?

Educate family members about normal growth and development patterns. Knowledge of normal growth and development is essential for family members to promote their own health and welfare throughout the lifespan, and to facilitate family functioning. Childbearing care includes interventions to assist in understanding and coping with psychological and physiologic changes during the childbearing period. Coping assistance includes interventions to assist the client in building on his or her strengths, to adapt to a change in function, or to achieve a higher level of function. Risk management includes interventions to initiate risk reduction activities.

Priority setting is based on the information obtained during reassessment. Priority setting is used to rank nursing diagnoses. Each of the following contributes to priority setting except which of the following?

Finances of the client

Go to the client and assess the client's pain.

Go to the client and assess the client's pain. The nurse's first action should always be to determine the cause of the client's pain in order to determine the correct intervention. After determining the cause, the nurse can plan how to proceed. The other steps would be appropriate, but only after the assessment.

A nurse is administering metformin to a client who has a new onset of diabetes mellitus type 2. Which of the following steps of nursing process is the nurse using

Implementation

A nurse is administering metformin to a client who has a new onset of diabetes mellitus type 2. Which of the following steps of nursing process is the nurse using?

Implementation

The nurse is preparing a client with a bowel obstruction for emergency surgery. Of the following interventions, which has the highest priority?

Inform the client what to expect after the surgery.

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

Inform the client what to expect after the surgery. Explanation: If the surgery is an emergency, the highest priority is to meet the client's immediate needs. The nurse should inform the client about what to expect after surgery. Discussing discharge plans, instructing in wound care, and teaching about dietary restrictions are important, but not necessary before the surgery.

The RN is orienting a new nurse who suggests a different way to perform a procedure. What is the RN's most appropriate reaction?

Listen to the new nurse's suggestion and evaluate its usefulness.

The nurse is caring for Mr. H., a 35-year-old man who is hospitalized following a motorcycle accident. He has a traumatic brain injury. The nurse is working with Mr. H. on self-care behaviors. The following would help the nurse to assess the success of the nursing interventions except which of the following?

Model self-care behaviors for the client.

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? - Nursing assistant - Licensed practical nurse - Registered nurse - A senior nursing student present for clinical

Nursing assistant Explanation: The nurse should avoid delegating the dressing change to the nursing assistant. The dressing change would be within the scope of practice of the registered nurse, licensed practical nurse, and the senior nursing student.

The nurse is coordinating care for the client with continuous pulse oximetry who requires pharyngeal suctioning. Which staff member should the nurse avoid delegating the task of suctioning?

Nursing assistant who is a nursing student

The nursing supervisor visits the emergency department and informs the department manager that tornado victims are expected to arrive within the hour. The department manager indicates the department has been slow and requests information regarding possible numbers of victims. The department manager reports supplies were just fully stocked, but two nurses are ill with influenza and were unable to report for their shift. Which resource does the department manager need to organize to respond to the disaster?

Personnel

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?

Praise the client for taking an active role in the client's care. Clients should be empowered to take responsibility for self-care. All clients should be taught that they have the power to question any part of their care. The nurse would appropriately praise the client. It is necessary to wash hands before taking vital signs; gloves are not required for the procedure. Telling the client that the nurse knows when to perform hand hygiene is disrespectful of the client's concern.

Which nursing intervention is appropriate for a risk nursing diagnosis? Select all that apply.

Prevent the problem. Reduce or eliminate risk factors. Monitor the client's status.

A nurse documents the diagnosis of: "Risk for Imbalanced Nutrition: More Than Body Requirements" for a client that is hospitalized. What is the major goal of interventions for a risk diagnosis?

Prevention of an actual problem

Psychosocial Supportive

After learning about a client's limited financial resources and limited insurance benefits, the home care nurse modifies nursing interventions related to a client's care instructions. The nurse modifies the plan of care based upon which client variable?

Psychosocial background

In the implementation step of the nursing process, a nurse is to utilize certain activities to be effective in the care of a client. Which activity is the priority?

Reassess client's needs.

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?

Reassess the appropriateness of the method of instruction.

A nurse is preparing to implement interventions identified on the clent's plan of care. Before implementing any intervention, which action would the nurse take first?

Reassess the client to determine if the action is needed.

Reassess the client to determine the effectiveness of the interventions.

A nurse in the intensive care unit (ICU) has been assigned to care for a client who was seriously injured during a gang rape. The nurse was raped 6 months ago and fears being too upset to care for the client properly. How should the nurse deal with the assignment? - Recognize the nurse's own limitations and ask another nurse to assist if the nurse becomes too emotional. - Recognize the issue and care for the client to the best of the nurse's ability. - Recognize that the nurse may be faced with this issue again and care for the client. - Recognize the nurse's own limitations and ask for another nurse to be assigned.

Recognize the nurse's own limitations and ask for another nurse to be assigned. Explanation: The nurse should keep the client's best interests in mind. If the nurse feels that the nurse's emotional state would compromise the client's care, the best course would be for the nurse to request a different assignment. The other courses of action leave the possibility that the client's care could be compromised.

The nurse is discussing diabetes mellitus with the family members of a client recently diagnosed. In order to promote the health of the family members, what would be the most important information for the nurse to include?

Risk factors and prevention of diabetes mellitus

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?

Surveillance Surveillance nursing interventions include detecting changes from baseline data and recognizing abnormal responses. Nurses rely on the senses to detect changes, such as observing the appearance and characteristics of clients and hearing by auscultation, pitch, and tone. Nurses use these surveillance activities to determine the current status of clients and changes from previous states. Maintenance nursing interventions involve the nurse assisting the client with performing routine activities of daily living. Supportive nursing measures involve providing basic comfort and emotional care to the client. Collaborative nursing interventions involve coordination and communication with health care professionals in other fields to meet the client's needs.

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? - Collaborative - Surveillance - Maintenance - Supportive

Surveillance Explanation: Surveillance nursing interventions include detecting changes from baseline data and recognizing abnormal responses. Nurses rely on the senses to detect changes, such as observing the appearance and characteristics of clients and hearing by auscultation, pitch, and tone. Nurses use these surveillance activities to determine the current status of clients and changes from previous states. Maintenance nursing interventions involve the nurse assisting the client with performing routine activities of daily living. Supportive nursing measures involve providing basic comfort and emotional care to the client. Collaborative nursing interventions involve cooridination and communication with health care professionals in other fields to meet the client's needs.

While observing a new nurse inserting an indwelling urinary catheter, the preceptor observes a break in sterile technique. What is the preceptor's first action?

Tell the new nurse that a break in sterile technique has occurred and the procedure must be stopped.

The nursing student is preparing to ambulate an obese client. The RN is concerned about the student's ability to safely ambulate the client. What would be the nurse's most appropriate action?

Tell the student that the RN will assist the student with the client's ambulation. The client's safety is always the nurse's primary concern.

The nurse is planning instruction on wound care to an adult client. What variables would cause the nurse to alter the education plan? Select all that apply.

The client is blind. The client denies the need for education.

What assessment data would indicate to the nurse at the conclusion of an education session that the client education was effective? Select all that apply.

The client verbalizes understanding of the instructions. The client is able to answer the nurse's questions. The client discusses the specifics of what was taught during the session.

The registered nurse is working with an unlicensed assistive personnel. Which client should the nurse not delegate to the unlicensed assistive personnel?

The client with continuous pulse oximetry who requires pharyngeal suctioning.

The nurse caring for a client who is recovering after a motor vehicle accident is planning for the client to begin increasing responsibility for self-care. What would be the nurse's most appropriate strategy?

The nurse encourages the client to take a shower instead of receiving a bed bath.

A client who has been in a vegetative state for years is scheduled for an elective surgery. The nurse is questioning whether the procedure is necessary. What is the nurse's appropriate first action?

The nurse should address the concern with the surgeon.

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? - "I sort my medication into an organizer every week." - "My wife's been gone for about 7 months now." - "My daughter has been staying with me the past few weeks." - "I asked my neighbors to help me with my yard work."

"My wife's been gone for about 7 months now." Explanation: The client's loss may be affecting how well the client is able to provide self-care. The client may be depressed and questioning the benefits of the health care regimen, or the client may have depended on the wife to help with health care and no longer has the ability to take care of himself. Assessment of the client allows the nurse to alter the plan of care to meet the client's needs. The statements concerning having a family member staying with the client, having help with the yard work, and sorting medications into an organizer all indicate factors that would improve the client's ability to provide self-care, not decrease it.

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? - "It is a hospital policy to reduce the potential for errors." - "We ask your name to ensure that we are treating the right client." - "We ask your name to show that we respect your rights." - "It is a habit that nurses develop in school."

"We ask your name to ensure that we are treating the right client." Explanation: The primary reason for asking the client to state the client's name is to ensure that the nurse is dealing with the correct client. Asking the client to state the client's name is a habit that should be developed in nursing school, but that is not the reason nurses ask clients for their names. It is not just a hospital-specific policy to ask the client for the client's name, but it is a step that is used in all client care situations. Respecting clients' rights is important but that is not why nurses ask for their names.

A nurse performs nurse-initiated nursing actions when caring for patients in a skilled nursing facility. Which are examples of these types of interventions? Select all that apply. - A nurse administers 500 mg of ciprofloxacin to a patient with pneumonia. - A nurse consults with a psychiatrist for a patient who abuses pain killers. - A nurse checks the skin of bedridden patients for skin breakdown. - A nurse orders a kosher meal for an orthodox Jewish patient. - A nurse records the I&O of a patient as prescribed by his health care provider. - A nurse prepares a patient for minor surgery according to facility protocol.

- A nurse checks the skin of bedridden patients for skin breakdown. - A nurse orders a kosher meal for an orthodox Jewish patient. - A nurse prepares a patient for minor surgery according to facility protocol Nurse-initiated interventions, or independent nursing actions, involve carrying out nurse-prescribed interventions resulting from their assessment of patient needs written on the nursing care plan, as well as any other actions that nurses initiate without the direction or supervision of another health care professional. Protocols and standard orders empower the nurse to initiate actions that ordinarily require the order or supervision of a health care provider. Consulting with a psychiatrist is a collaborative intervention.

A student nurse is organizing clinical responsibilities for a patient who is diabetic and is being treated for foot ulcers. The patient tells the student, "I need to have my hair washed before I can do anything else today; I'm ashamed of the way I look." The patient's needs include diagnostic testing, dressing changes, meal planning and counseling, and assistance with hygiene. How would the nurse best prioritize this patient's care? - Explain to the patient that there is not enough time to wash her hair today because of her busy schedule. - Schedule the testing and meal planning first and complete hygiene as time permits. - Perform the dressing changes first, schedule the testing and counseling, and complete hygiene last. - Arrange to wash the patient's hair first, perform hygiene, and schedule diagnostic testing and counseling.

- Arrange to wash the patient's hair first, perform hygiene, and schedule diagnostic testing and counseling. As long as time constraints permit, the most important priorities when scheduling nursing care are priorities identified by the patient as being most important. In this case, washing the patient's hair and assisting with hygiene puts the patient first and sets the tone for an effective nurse-patient partnership.

The nurse is attending a conference on evidence-based practice. Which statement by the nurse indicates further education is needed? - "I can learn about evidence-based practice by reading professional nursing journals." - "The Agency for Healthcare Research and Quality is a resource for evidence-based practice." - "Nursing interventions should be supported by a sound scientific rationale." - "I must conduct research to validate the usefulness of my nursing interventions."

"I must conduct research to validate the usefulness of my nursing interventions." Explanation: Nursing interventions should be supported by a sound scientific rationale; however, nurses do not need to personally conduct research to establish the rationale for nursing interventions. Nurses can learn about evidence-based practice by reading professional nursing journals, attending nursing workshops, and consulting evidence-based practice resources, such as the Agency for Healthcare Research and Quality.

A nurse case manager is explaining the role of a case manager to a group of nursing students. One student asks if the case manager misses providing client care. What is the case manager's best response?

"I provide indirect care to my clients by coordinating their treatment with other disciplines."

The nurse is currently completing the last of three consecutive night shifts. The unit will be short-staffed on day shift and the charge nurse wants the nurse to work this as an overtime shift. What is the nurse's most appropriate response?

"I will not work tomorrow because I would be a danger to my clients."

A nurse is preparing to implement interventions for a client based on the client's plan of care. To ensure the nurse is successful in implementing the plan, which question would be important for the nurse ask himself/herself? Select all that apply.

"Is the client prepared for what needs to be done?" "Do I have all the necessary supplies and equipment needed?" "Do I have the skills to perform the interventions?" "Can I do the intervention alone or do I need help?" "Do I know what to do if something happens?"

A client with diabetes who has been closely following the prescribed plan of care for over a year is being seen at an outpatient setting. The client has not brought a log of daily glucose checks and tells the nurse, "I haven't been doing them regularly." What is the nurse's most therapeutic statement to the client?

"It seems like you are having difficulty with your care regimen."

A client with diabetes who has been closely following the prescribed plan of care for over a year is being seen at an outpatient facility. The client has not brought a log of daily glucose checks and tells the nurse, "I haven't been doing them regularly." What is the nurse's most therapeutic statement to the client? - "Should I instruct your family to do the glucose checks for you?" - "Should I arrange for a home health nurse to coordinate your care?" - "It seems like you are having difficulty with your care regimen." - "It is extremely important to your health to strictly follow your plan of care."

"It seems like you are having difficulty with your care regimen." Explanation: The nurse's open-ended statement acknowledging that the client is having difficulty with the care regimen encourages the client to discuss what has occurred that has caused the client to not manage the diabetes as was previously done. The statement reminding the client that health care is important will discourage the client to freely discuss any problems. A home health nurse or instructions given to the family may be indicated, but not until the client has verbalized the reasons why the care regimen has not been followed.

A nurse develops a detailed care plan for a 16-year-old patient who is a new single mother of a premature infant. The plan includes collaborative care measures and home health care visits. When presented with the plan, the patient states, "We will be fine on our own. I don't need any more care." What would be the nurse's best response? - "You know your personal situation better than I do, so I will respect your wishes." - "If you don't accept these services, your baby's health will suffer." - "Let's take a look at the plan again and see if we can adjust it to fit your needs." - "I'm going to assign your case to a social worker who can explain the services better."

"Let's take a look at the plan again and see if we can adjust it to fit your needs." When a patient does not follow the care plan despite your best efforts, it is time to reassess strategy. The first objective is to identify why the patient is not following the therapy. If the nurse determines, however, that the care plan is adequate, the nurse must identify and remedy the factors contributing to the patient's noncompliance.

An 84-year-old male has been admitted to the hospital several times in the past few months for exacerbations of chronic obstructive pulmonary disease (COPD) and elevated blood glucose. Which statement by the client could help identify the most likely reason for the changes in his health status?

"My wife's been gone for about 7 months now."

The nurse is caring for a client who does not speak the same language. The unlicensed assistive personnel (UAP) speaks the same language as the client. What parts of communicating with the client could the nurse appropriately delegate to the UAP? Select all that apply. - Demonstrate and teach new caregiving procedures to the family. - Ask the client questions regarding personal care needs. - Orient the client and family to the room, including the call light button. - Provide education to the client, including discharge instructions. - Counsel the client about making adjustments to a new medical condition. - Interview the client as part of the admission assessment.

- Ask the client questions regarding personal care needs. - Orient the client and family to the room, including the call light button. Explanation: Delegation to a UAP requires knowledge of the registered nurse (RN) role and what tasks can be legally delegated. The RN can delegate asking clients questions about personal care needs and orientation to the room (for example, the call light button). It is inappropriate to have the UAP interview the client as part of the admission assessment, provide education to the client or family, or counsel the client. Those duties are legally the role of the RN and would be most appropriately addressed with a the assistance of a professional interpreter.

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. - Transporting the infant to the mother's room according to hospital policy - Providing routine discharge instructions related to infant care - Initial assessment of the mother after birth of the infant - Assisting the client with personal hygiene needs and ambulation - Assisting and teaching the client to breastfeed the infant

- Assisting the client with personal hygiene needs and ambulation - Transporting the infant to the mother's room according to hospital policy Explanation: It is essential when delegating duties that the registered nurse (RN) is aware the nurse's role and what duties can be delegated. The nurse also must be aware of the training and the competence of the UAP. The nurse could appropriately delegate assisting with personal hygiene needs, ambulation, and transporting the infant to the mother's room according to hospital policy. Assessment is the role of the RN and cannot be delegated. Teaching, including breastfeeding education and discharge instructions, is also the role of the RN and cannot be delegated.

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

- Collecting additional client data - Modifying the client plan of care Explanation: During the implementation phase the nurse carries out the plan of care, continues data collection, modifies the plan of care as needed, and documents the care provided. Performing an initial assessment and collecting a database are components of the assessment (data collection) phase of the nursing process. Developing client outcomes and goals is part of the planning phase. Measuring achievement of goals is part of the evaluation phase of the nursing process.

An RN working on a busy hospital unit delegates patient care to UAPs. Which patient care could the nurse most likely delegate to a UAP safely? Select all that apply. - Performing the initial patient assessments - Making patient beds - Giving patients bed baths - Administering patient medications - Ambulating patients - Assisting patients with meals

- Making patient beds - Giving patients bed baths - Ambulating patients - Assisting patients with meals Performing the initial patient assessment and administering medications are the responsibility of the RN. In most cases, patient hygiene, bed-making, ambulating patients, and helping to feed patients can be delegated to a UAP.

Nurses use the NIC Taxonomy structure as a resource when planning nursing care for patients. What information is found in this structure? - Case studies illustrating a complete set of activities that a nurse performs to carry out nursing interventions - Nursing interventions, each with a label, a definition, and a set of activities that a nurse performs to carry it out, with a short list of background readings - A complete list of nursing diagnoses, outcomes, and related nursing activities for each nursing intervention - A complete list of reimbursable charges for each nursing intervention

- Nursing interventions, each with a label, a definition, and a set of activities that a nurse performs to carry it out, with a short list of background readings The NIC Taxonomy lists nursing interventions, each with a label, a definition, a set of activities that a nurse performs to carry it out, and a short list of background readings. It does not contain case studies, diagnoses, or charges.

A school nurse notices that a student is losing weight and decides to perform a focused nutritional assessment to rule out an eating disorder. What is the nurse's best action? - Perform the focused assessment as this is an independent nurse-initiated intervention. - Request an order from Jill's physician since this is a physician-initiated intervention. - Request an order from Jill's physician since this is a collaborative intervention. - Request an order from the nutritionist since this is a collaborative intervention.

- Perform the focused assessment as this is an independent nurse-initiated intervention. Performing a focused assessment is an independent nurse-initiated intervention; thus the nurse does not need an order from the physician or the nutritionist.

A nurse is about to perform pin site care for a patient who has a halo traction device installed. What is the FIRST nursing action that should be taken prior to performing this care? - Administer pain medication. - Reassess the patient. - Prepare the equipment. - Explain the procedure to the patient.

- Reassess the patient. Before implementing any nursing action, the nurse should reassess the patient to determine whether the action is still needed. Then the nurse may collect the equipment, explain the procedure, and, if necessary, administer pain medications.

Which roles are a responsibility of the nurse in the nurse-health care team relationship? Select all that apply. - Serve as a liaison between the client and family and the health care team. - Educate the family to be informed and assertive consumers of health care. - Support the nursing care given by other nursing personnel. - Provide creative leadership to make the nursing unit a satisfying and challenging place to work. - Coordinate the inputs of the multidisciplinary team into a comprehensive plan of care.

- Serve as a liaison between the client and family and the health care team. - Coordinate the inputs of the multidisciplinary team into a comprehensive plan of care. Explanation: Responsibilities of the nurse in the nurse-health care team relationship include serving as a liaison between the client and family and the health care team and coordinating the inputs of the multidisciplinary team into a comprehensive plan of care. In the nurse-nurse relationship, the nurse provides creative leadership to make the nursing unit a satisfying and challenging place to work and supports the nursing care given by other nursing personnel. Educating the family to be informed and assertive consumers of health care is a role responsibility in the nurse-client-family relationship.

What are the advantages of using standard Nursing Interventions Classifications (NIC)? Select all that apply. - Allocating nursing resources - Allowing the use of multiple systems of nomenclature - Teaching decision making - Developing information systems - Limiting the amount of reimbursement allowed for nursing services - Communicating nursing to non-nurses

- Teaching decision making - Allocating nursing resources - Developing information systems - Communicating nursing to non-nurses Explanation: Each of the interventions listed in the NIC has a label, a definition, a set of activities that a nurse performs to carry out the intervention, and a short list of background readings. This information encourages the teaching of decision making to new nurses and helps administrators plan more effectively for staff and equipment needs (nursing resources) and examine the effectiveness and cost of nursing care. The NIC also promotes communication of the nature of nursing to the public. The goal is not to limit but to encourage reimbursement for nursing services. The NIC allows for a standardized nomenclature rather than multiple systems of nomenclature.

A student nurse is on a clinical rotation at a busy hospital unit. The RN in charge tells the student to change a surgical dressing on a patient while she takes care of other patients. The student has not changed dressings before and does not feel confident performing the procedure. What would be the student's best response? - Tell the RN that he or she lacks the technical competencies to change the dressing independently. - Assemble the equipment for the procedure and follow the steps in the procedure manual. - Ask another student nurse to work collaboratively with him or her to change the dressing. - Report the RN to his or her instructor for delegating a task that should not be assigned to student nurses.

- Tell the RN that he or she lacks the technical competencies to change the dressing independently. Student nurses should notify their nursing instructor or nurse mentor if they believe they lack any competencies needed to safely implement the care plan. It is within the realm of a student nurse to change a dressing if he or she is technically prepared to do so.

A new RN is being oriented to a nursing unit that is currently understaffed and is told that the UAPs have been trained to obtain the initial nursing assessment. What is the best response of the new RN? - Allow the UAPs to do the admission assessment and report the findings to the RN. - Do his or her own admission assessments but don't interfere with the practice if other professional RNs seem comfortable with the practice. - Tell the charge nurse that he or she chooses not to delegate the admission assessment until further clarification is received from administration. - Contact his or her labor representative to report this practice to the state board of nursing.

- Tell the charge nurse that he or she chooses not to delegate the admission assessment until further clarification is received from administration. The nurse should not delegate this nursing admission assessment because only nurses can perform this intervention. The nurse should seek clarification for this policy from the nursing administration.

The nurse is planning instruction on wound care to an adult client. What variables would cause the nurse to alter the education plan? Select all that apply. - The client is blind. - The client is an architect. - The client is male. - The client is married. - The client denies the need for education.

- The client is blind. - The client denies the need for education. Explanation: The client's blindness will require the nurse to alter the education plan to fit the client's needs. The education might also require teaching another person to perform the wound care. If the client denies the need for education, attempting to teach the client at this time will be ineffective. The nurse will need to determine why the client denies the need for teaching and address that issue first. The facts that the client is male, married, and an architect do not have any bearing on the instruction.

What assessment data would indicate to the nurse at the conclusion of an education session that the client education was effective? Select all that apply. - The client discusses the specifics of what was taught during the session. - The client tells the nurse that the client's spouse will handle the care. - The client verbalizes understanding of the instructions. - The client is able to answer the nurse's questions. - The client asks the nurse to repeat the instructions.

- The client verbalizes understanding of the instructions. - The client is able to answer the nurse's questions. - The client discusses the specifics of what was taught during the session. Explanation: After an intervention is implemented, the nurse must assess the effectiveness of the intervention. The client stating an understanding of the instructions gives the nurse an indication that learning has taken place. Asking the client questions and receiving the correct answers is an excellent way to judge the client's knowledge. The client asking for the nurse to repeat the instructions shows that the client does not have a clear understanding. The client's statement that the spouse will handle the care signals that the client is not ready to learn at this time. The client's ability to discuss the specifics of the material suggests that learning has taken place.

What assessment data would indicate to the nurse at the conclusion of an education session that the client education was effective? Mark all that apply.

- The client verbalizes understanding of the instructions. -The client is able to answer the nurse's questions. -The client discusses the specifics of what was taught during the sessio

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. -The client's oxygen saturation level increases. - The client states, "I can breathe easier now." - The client's respiratory rate decreases. - The client is watching television. - The client's family asks if the client is going to be okay.

- The client's respiratory rate decreases. - The client states, "I can breathe easier now." - The client's oxygen saturation level increases. Explanation: When reassessing the client after implementing interventions to increase oxygenation, the nurse would look for a decrease in respiratory rate to a more normal rate and an increase in the oxygen saturation level. The client's subjective statement of breathing easier would also indicate effectiveness. The client watching television and the client's family's statement do not indicate anything about oxygenation status.

A nurse is using the implementation step of the nursing process to provide care for patients in a busy hospital setting. Which nursing actions best represent this step? Select all that apply. - The nurse carefully removes the bandages from a burn victim's arm. - The nurse assesses a patient to check nutritional status. - The nurse formulates a nursing diagnosis for a patient with epilepsy. - The nurse turns a patient in bed every 2 hours to prevent pressure injuries. - The nurse checks a patient's insurance coverage at the initial interview. - The nurse checks for community resources for a patient with dementia.

- The nurse carefully removes the bandages from a burn victim's arm. - The nurse turns a patient in bed every 2 hours to prevent pressure injuries. - The nurse checks for community resources for a patient with dementia. During the implementing step of the nursing process, nursing actions planned in the previous step are carried out. The purpose of implementation is to assist the patient in achieving valued health outcomes: promote health, prevent disease and illness, restore health, and facilitate coping with altered functioning. Assessing a patient for nutritional status or insurance coverage occurs in the assessment step, and formulating nursing diagnoses occurs in the diagnosing step.

Which nursing actions reflect the implementing step of nursing process? (Select all that apply.)

-Providing health education to reduce health risks -Referring the client to community resources, when necessary -Using evidence-based interventions individualized for the clien

The nurse assigned to care for a client that has received a sedative has asked the unlicensed assistive personnel (UAP) to help the client to the toilet. The nurse demonstrates proper delegation skills by performing which actions? (Select all that apply.)

-confirming the UAP has successfully passed this skill competency -being available for questions from the UAP -giving a report on the client to the UAP and answering questions -confirming that the UAP has repeatedly completed similar tasks

The nurse is assigning interventions to achieve the goals set for a client using the nursing intervention classification (NIC). What is the benefit of using this system for the development of interventions? Select all that apply.

-creation of a standardized language -assistance in determining the cost of services that nurses provide -demonstration of the impact of nurses

A client with a high fever receiving intravenous fluids, antibiotics, and oxygen For delegation, the circumstances must be right. The health condition of the client must be stable. The client with a high fever receiving intravenous fluids, antibiotics, and oxygen is the least stable of the clients listed and should be assessed by the nurse. Delegation of taking vital signs would be appropriate for all of the other client's described.

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? - An adult client who is being treated for kidney stones - A client with a high fever receiving intravenous fluids, antibiotics, and oxygen - An older adult with pneumonia who is being discharged to the son's home tomorrow - A middle-aged client who had abdominal surgery 3 days ago and is ambulating in the hall

A client with a high fever receiving intravenous fluids, antibiotics, and oxygen Explanation: For delegation, the circumstances must be right. The health condition of the client must be stable. The client with a high fever receiving intravenous fluids, antibiotics, and oxygen is the least stable of the clients listed and should be assessed by the nurse. Delegation of taking vital signs would be appropriate for all of the other client's described.

Which examples of nursing actions involve direct care of the client? Select all that apply.

A nurse counsels a young family who is interested in natural family planning. A nurse massages the back of a client while performing a skin assessment. A nurse helps a client in hospice fill out a living will form

Which statement by a nurse case manager regarding this nurse's role in client care is most accurate? A) "I provide indirect care to my clients by coordinating their treatment with other disciplines." B) "Even though I do not provide care to clients, my work is very important." C) "I provide a critical service that is necessary for financial reimbursement." D) "Moving away from client care is a necessary step to advancing my career."

A) "I provide indirect care to my clients by coordinating their treatment with other disciplines."

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

A) Administering a glycerin suppository to a constipated client who has not responded to oral stool softeners

The nurse is working with a client who is having a difficult time accepting a new diagnosis of type 2 diabetes. The nurse pulls up a chair and holds the client's hand while listening to the client's concerns. What additional type of nursing supportive intervention could the nurse provide? A) Arranging for clergy to visit with the client B) Teaching the client how to administer medications C) Providing humor in conversation to assist in alleviating stress D) Arranging appointments with a specialist after the client is discharged

A) Arranging for clergy to visit with the client

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

A) Assess the client to determine the cause of the pain.

The nurse has assisted the client to ambulate for the first time. After returning the client to bed, what is the nurse's priority intervention? A) Assess the client's response to the ambulation. B) Inform the client when ambulation is scheduled next. C) Discuss the client's feelings about the illness. D) Document the client's ambulation.

A) Assess the client's response to the ambulation.

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

A) Bed bath for the newly admitted client who has multiple skin lesions

Which parties are essential for the nurse to include in the implementation of a client's plan of care? A) Client, family, and physician B) Client, physician, and hospital director C) Client, physical therapist, and nursing staff D) Client, surgeon, and physician

A) Client, family, and physician

A client on the medical-surgical unit is scheduled for several diagnostic tests. The nurse is concerned that the tests will be too tiring for the client. What would be the nurse's mostappropriate action? A) Coordinate with the other disciplines to schedule the tests with adequate rest for the client. B) Coordinate with the other disciplines to determine if all the tests scheduled are necessary. C) Review the physician's progress notes to determine if any of the tests are not indicated. D) Instruct the client to refuse the diagnostic tests if the client becomes too fatigued.

A) Coordinate with the other disciplines to schedule the tests with adequate rest for the client.

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) Ask the client if the client has any questions. D) Leave written information for the client to read later.

A) Delay the instruction until the visitors leave.

A nurse is preparing to educate a client about self-care after cataract surgery. Which should the nurse do first? A) Determine the client's willingness to follow the regimen. B) Identify changes from the baseline. C) Ensure physician approval for the education plan. D) Instruct the unlicensed assistive personnel on what to teach the client.

A) Determine the client's willingness to follow the regimen.

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) What is the client's condition? C) How can I supervise the completion of this task? D) How can I explain the task to the UAP?

A) Does this task fall within the scope of a UAP?

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

A) Does this treatment make sense for this client?

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 understands proper wound care techniques? A) Include family members or other caregivers in the education. B) Delegate teaching to unlicensed assistive personnel (UAP). C) Provide a video demonstration of abdominal wound care. D) Document client education prior to discharge from the unit.

A) Include family members or other caregivers in the education.

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) Reassess the client to determine the effectiveness of the 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) Perform additional nonpharmacological pain interventions.

A) Reassess the client to determine the effectiveness of the interventions.

A nurse in the intensive care unit (ICU) has been assigned to care for a client who was seriously injured during a gang rape. The nurse was raped 6 months ago and fears being too upset to care for the client properly. How should the nurse deal with the assignment? A) Recognize the nurse's own limitations and ask for another nurse to be assigned. B) Recognize that the nurse may be faced with this issue again and care for the client. C) Recognize the nurse's own limitations and ask another nurse to assist if the nurse becomes too emotional. D) Recognize the issue and care for the client to the best of the nurse's ability.

A) Recognize the nurse's own limitations and ask for another nurse to be assigned.

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 need for education. C) Assist the client to the bedside commode. D) Assess the client's risk for pressure injuries. E) Administer routine oral medications.

A) Record the client's intake and output. C) Assist the client to the bedside commode.

A client with hypertension being seen for follow-up care has a blood pressure of 160/100 mm Hg. The client reports following the treatment regimen closely and that blood pressure readings have been elevated for the last 2 weeks. What is the nurse's most appropriate action? A) Report the findings to the physician for further plans. B) Reinforce the instructions for the treatment regimen to the client. C) Interview the family to determine if the client is giving accurate information. D) Inform the client that the blood pressure medication will have to be changed.

A) Report the findings to the physician for further plans.

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) Consult with the physical therapist to determine the client's ability. D) Instruct the client's family to assist the client to ambulate to the bathroom.

A) Revise the care plan to allow the client to ambulate to the bathroom independently.

A new unlicensed assistive personnel (UAP) is preparing to ambulate an obese client. The registered nurse (RN) is concerned about the UAP's ability to safely ambulate the client. Which would be the nurse's most appropriate action? A) Tell the UAP that the RN will assist the UAP with the client's ambulation. B) Tell the UAP that a different UAP should ambulate the client. C) Tell the UAP not to ambulate the client at this time. D) Tell the UAP to ask the client whether the client is comfortable with the UAP assisting ambulation.

A) Tell the UAP that the RN will assist the UAP with the client's ambulation.

What assessment data would indicate to the nurse at the conclusion of an education session that the client education was effective? Select all that apply. A) The client verbalizes understanding of the instructions. B) The client is able to answer the nurse's questions. C) The client asks the nurse to repeat the instructions. D) The client tells the nurse that the client's spouse will handle the care. E) The client discusses the specifics of what was taught during the session.

A) The client verbalizes understanding of the instructions. B) The client is able to answer the nurse's questions. E) The client discusses the specifics of what was taught during the session.

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's respiratory rate decreases. B) The client states, "I can breathe easier now." C) The client's oxygen saturation level increases. D) The client is watching television. E) The client's family asks if the client is going to be okay.

A) The client's respiratory rate decreases. B) The client states, "I can breathe easier now." C) The client's oxygen saturation level increases.

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 should inform the charge nurse that the nurse does not have the experience to properly care for this client.

Which of the following nursing interventions is most likely to be allowed within the parameters of a protocol or standing order?

Administering a glycerin suppository to a constipated client who has not responded to oral stool softeners

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

Administering a glycerin suppository to a constipated client who has not responded to oral stool softeners Explanation: Standing orders and protocols often surround the management of bowel elimination. Modification of a client's IV fluid or administration of a new antihypertensive are client-specific interventions that are physician initiated. The care team cannot independently change a client's advance directive.

A client requires a change and reapplication of a colostomy bag. The nurse has never changed an ostomy bag before. What is the nurse's best course of action? - Ask a skilled nurse to assist with the procedure. - Ask the client how the bag is changed. - Read the policy and procedure manual. - Determine the necessity of the bag change.

Ask a skilled nurse to assist with the procedure. Explanation: Professional nurses should only undertake tasks that they have been properly trained to perform. Because the nurse has no experience in changing an ostomy bag, it would be most appropriate to have the assistance of an experienced nurse. It would be inappropriate to ask the client how the bag is changed. The client is relying on the nurse to have the necessary technical knowledge. Reading the policy and procedure manual alone would not ensure the successful completion of the procedure. The necessity of the ostomy bag change has already been established.

Ask the client questions regarding personal care needs. Orient the client and family to the room, including the call light button.

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?

Ask the client to verbalize the medication regimen and diet modifications required

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?

Ask the client to verbalize the medication regimen and diet modifications required. If the nurse suspects a client does not understand instructions, the first step is to assess the client's understanding. The most effective way to do that is to have the client repeat the client's understanding of the instructions. The other steps might be interventions that the nurse would institute after determining the client's needs.

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? - Refer the client to available community resources and support groups. - Ask the gastroenterologist to explain the treatment plan to the client and family again. - Ask the client to verbalize the medication regimen and diet modifications required. - Ask the nutritionist to give the client strict meal plans to follow.

Ask the client to verbalize the medication regimen and diet modifications required. Explanation: If the nurse suspects a client does not understand instructions, the first step is to assess the client's understanding. The most effective way to do that is to have the client repeat the client's understanding of the instructions. The other steps might be interventions that the nurse would institute after determining the client's needs.

One hour after receiving pain medication, a postoperative client reports intense pain. What is the nurse's appropriate first action?

Assess the client to determine the cause of the pain

One hour after receiving pain medication, a postoperative client reports intense pain. What is the nurse's appropriate first action?

Assess the client to determine the cause of the pain.

One hour after receiving pain medication, a postoperative client reports intense pain. What is the nurse's appropriate first action?

Assess the client to determine the cause of the pain. One hour after administering pain medication, the nurse would expect the client to be relieved of pain. A new report of intense pain might signal a complication and requires a thorough assessment. The nurse might request an order for additional pain medication, but only after a thorough assessment. Telling the client how often medication can be received does not help relieve the client's pain. Repositioning and splinting the incision are interventions that the nurse might perform, but only after determining the cause of the pain.

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

Assess the client to determine the cause of the pain. Explanation: One hour after administering pain medication, the nurse would expect the client to be relieved of pain. A new report of intense pain might signal a complication and requires a thorough assessment. The nurse might request an order for additional pain medication, but only after a thorough assessment. Telling the client how often medication can be received does not help relieve the client's pain. Repositioning and splinting the incision are interventions that the nurse might perform, but only after determining the cause of the pain.

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?

Assess the client's blood pressure to determine if the medication is indicated.

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? - Tell the client to report any side effects experienced. - Ask the client to verbalize the purpose of the medication. - Determine the client's reaction to the medication in the past. - Assess the client's blood pressure to determine if the medication is indicated.

Assess the client's blood pressure to determine if the medication is indicated. Explanation: Before initiating any intervention, the nurse must determine if the intervention is still necessary. Before administering blood pressure medication, the blood pressure must be assessed. The client's reaction to the medication previously does not indicate if the medication is indicated at this time. The client's ability to verbalize the purpose of the medication is important to promote self-care, but it is not important for the client's safety at this time. The client's report of side effects would indicate an adverse reaction after the medication is administered, but it would not protect the client's safety before the medication is given.

The nurse has assisted the client to ambulate for the first time. After returning the client to bed, what is the nurse's priority intervention? - Document the client's ambulation. - Assess the client's response to the ambulation. - Discuss the client's feelings about the illness. - Inform the client when ambulation is scheduled next.

Assess the client's response to the ambulation. Explanation: After a nurse has performed an intervention, the next step is to evaluate the effectiveness of the intervention. The nurse should assess the client's response to the ambulation. Informing the client when ambulation is scheduled next, discussing the client's feelings, and documenting the ambulation are important, but not until after the client has been reassessed.

Assist the client to identify strategies to promote safety in the home.

A busy nurse is working with an unlicensed assistive personnel (UAP). What tasks can the nurse appropriately delegate to the UAP? Select all that apply.

Assist the client to the bedside commode. Record the client's intake and output.

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

Auscultating of bilateral lung sounds Explanation: Surveillance or monitoring nursing interventions include detecting changes from baseline data and recognizing abnormal responses. Nurses rely on the senses to detect changes: observing the appearance and characteristics of clients; hearing by auscultation, pitch, and tone; detecting odors and comparing them with past experience and knowledge of specific problems; and using touch to assess body temperature, skin condition, clamminess, or diaphoresis. Nurses use all of these surveillance or monitoring activities to determine the current status of clients and changes from previous states. Nurses often detect subtle changes in a client's condition and communicate them to the physician to minimize problems. Providing hygiene and administering a paracetamol tablet are examples of maintenance nursing interventions. Use of therapeutic communication skills is an example of a supportive nursing intervention.

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) Determine the client's reaction to the medication in the past. B) Assess the client's blood pressure to determine if the medication is indicated. C) Ask the client to verbalize the purpose of the medication. D) Tell the client to report any side effects experienced.

B) Assess the client's blood pressure to determine if the medication is indicated.

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) Assisting the client with personal hygiene needs and ambulation C) Assisting and teaching the client to breastfeed the infant D) Providing routine discharge instructions related to infant care E) Transporting the infant to the mother's room according to hospital policy

B) Assisting the client with personal hygiene needs and ambulation E) Transporting the infant to the mother's room according to hospital policy

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 the risks and benefits of a blood transfusion with the client. B) Discuss possible alternatives to a blood transfusion with the physician. C) Discuss the client's options with other church members. D) Discuss the client's refusal with hospital risk managers.

B) Discuss possible alternatives to a blood transfusion with the physician.

A nurse is catheterizing a client. Which scenario demonstrates steps the nurse would take to ensure client respect and privacy? A) Verify the client's identifiable information, explain the procedure to the family, and pull the privacy curtain to allow the client to feel comfortable in having family close by. B) Explain the procedure to the client, close the door to the room, and cover all areas of the client, only exposing the area for catheterization. C) Ask family members to leave the room briefly, close the door, and ask the client if he or she would like a sheet to cover oneself. D) Bring in another nurse to provide support and prevent questionable behaviors, explain the procedure to the client, and close the door and privacy curtain prior to beginning the procedure.

B) Explain the procedure to the client, close the door to the room, and cover all areas of the client, only exposing the area for catheterization.

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) Identify what barriers the client feels are preventing adherence with the plan. C) Collaborate with other health care professionals about the client's treatment. D) Change the nursing care plan.

B) Identify what barriers the client feels are preventing adherence with the plan.

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

B) Inform the client what to expect after the surgery.

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) Nurse case manager

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) Registered nurse B) Nursing assistant C) A senior nursing student present for clinical D) Licensed practical nurse

B) Nursing assistant

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) Registered nurse B) Nursing assistant who is a nursing student C) A senior nursing student present for clinical D) Licensed practical nurse

B) Nursing assistant who is a nursing student

The emergency room (ER) has a strict protocol regarding intramuscular (IM) injection technique. A nurse working in the ER has learned of a new technique to decrease pain with IM injections from the nursing literature and would like to use it. What is the most appropriate way for the nurse to implement the technique? A) Begin using the technique to determine whether it is effective. B) Petition to change the protocol based on the new evidence. C) Ask the ER physician to order IM injections with the new technique. D) Research the protocols at other area emergency rooms.

B) Petition to change the protocol based on the new evidence.

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) Reassess the appropriateness of the method of instruction.

The registered nurse (RN) is delegating the task of assisting a postoperative client to the bathroom to the unlicensed assistive personnel (UAP). The nurse witnessed the UAP correctly perform the task on previous occasions and knows the UAP is competent to perform the task. The nurse has communicated how to get the client out and back into bed and told the UAP not to allow the client to bear weight on the left leg. The nurse validated that the activity was completed and gave the UAP feedback. Which delegation guideline did the nurse omit? A) Right task B) Right circumstance C) Right person D) Right supervision

B) Right circumstance

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) Medications used to treat diabetes mellitus B) Risk factors for and prevention of diabetes mellitus C) The severity of the client's disease D) The cellular metabolism of glucose

B) Risk factors for and prevention of diabetes mellitus

The nurse is caring for a postoperative client who is receiving morphine sulfate for pain management. The nurse obtains the following vital signs: heart rate, 74 beats/min; respiratory rate, 8 breaths/min; blood pressure, 114/68 mm Hg. After reviewing the nursing care plan and physician orders, the nurse administers naloxone. Which would allow the nurse to initiate this action? A) Algorithm B) Standing orders C) Protocol D) Order set

B) Standing orders

The client has a diagnosis of Risk for Injury related to falls. How would the nurse know if the intervention was successful? A) The client calls for assistance to get out of bed. B) The client is free of falls. C) The client is taught safety precautions. D) The client verbalizes risks for injury.

B) The client is free of falls.

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

Bed bath for the newly admitted client who has multiple skin lesions Explanation: The safest delegation is to have the UAP bathe the client with skin lesions and report any abnormal findings to the nurse. Preparing insulin is outside of the UAP's scope of practice. The UAP may have the skills to insert an indwelling catheter and ambulate clients, but the clients involved each have qualifiers that complicate the tasks.

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) "It is a habit that nurses develop in school." B) "It is a hospital policy to reduce the potential for errors." C) "We ask your name to ensure that we are treating the right client." D) "We ask your name to show that we respect your rights."

C) "We ask your name to ensure that we are treating the right client."

The client tells the nurse, "I think the nurse last night may have given me the wrong medication, but I was afraid to say anything." What is the nurse's most appropriate response? A) "I will report your concerns to the nurse manager." B) "I will discuss your concerns with the night nurse." C) "You should always speak up if you have any questions about your care." D) "You always have the right to refuse any medication or treatment."

C) "You should always speak up if you have any questions about your care."

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

C) A client with a high fever receiving intravenous fluids, antibiotics, and oxygen

A client requires a change and reapplication of a colostomy bag. The nurse has never changed an ostomy bag before. What is the nurse's best course of action? A) Ask the client how the bag is changed. B) Read the policy and procedure manual. C) Ask a skilled nurse to assist with the procedure. D) Determine the necessity of the bag change.

C) Ask a skilled nurse to assist with the procedure.

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) Ask the surgeon to wait until the client has had a chance to talk to the spouse.

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) Instruct the client about the need to keep the walkway to the bathroom clear. C) Assist the client to identify strategies to promote safety in the home. D) Assign a home health aide to perform housekeeping duties.

C) Assist the client to identify strategies to promote safety in the home.

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) Auscultating of bilateral lung sounds

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) Continue the education and remind the client that it is essential to learn self-care. B) Medicate the client for anxiety and continue the education later. C) Discontinue the education and attempt at another time. D) Discontinue the education and ask the client for permission to teach a family member.

C) Discontinue the education and attempt at another time.

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) Review with the client the risks and benefits of surgery. B) Ask the client to discuss the decision with family members. C) Discuss with the client the reasons for declining surgery. D) Notify the physician of the client's refusal.

C) Discuss with the client the reasons for declining surgery.

The nurse in a burn intensive care unit (BICU) is caring for a 3-year-old child who was burned with scalding hot water. The client has burns covering 75% of the body. The client's condition is critical but stable. At 1000, the nurse reassesses the client and finds that the client is agitated and pulling at the endotracheal tube. Which is the nurse's priority intervention for this client at this time? A) Providing medication for agitation B) Repositioning to prevent pressure injuries C) Ensuring that the endotracheal tube is secure D) Changing the dressing to prevent infection

C) Ensuring that the endotracheal tube is secure

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

C) Helping to allay a client's fears about surgery

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

C) It enables the nurse to revise the care plan appropriately.

The physician has ordered that the client should ambulate 3 times a day. The nurse enters the room to ambulate the client and the client reports pain. What is the nurse's most appropriate action? A) Ambulate the client and medicate later. B) Emphasize to the client the importance of following the treatment plan. C) Medicate the client and wait to ambulate later. D) Explain to the client the benefits of ambulation.

C) Medicate the client and wait to ambulate later.

A nurse is administering metformin to a client who has a new onset of diabetes mellitus type 2. Which step should the nurse consider a priority on the nursing care plan? A) Restrict intake of foods and fluids. B) Monitor for noncompliance. C) Monitor for lactic acidosis D) Administer B12 injections

C) Monitor for lactic acidosis

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) Inform the client that it is not necessary to wash hands before vital signs. B) Reassure the client that the nurse knows when to perform hand hygiene. C) Praise the client for taking an active role in the client's care. D) Tell the client that gloves are required for this procedure.

C) Praise the client for taking an active role in the client's care.

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

C) Provide the client with assistance in transferring to the bedside commode.

The nurse is planning instruction on wound care to an adult client. What variables would cause the nurse to alter the education plan? Select all that apply. A) The client is male. B) The client is married. C) The client is blind. D) The client is an architect. E) The client denies the need for education.

C) The client is blind. E) The client denies the need for education.

The registered nurse is working with an unlicensed assistive personnel. Which client should the nurse not delegate to the unlicensed assistive personnel? A) The client who needs vital signs taken following infusion of packed red blood cells. B) The client who requires assistance dressing in preparation for discharge. C) The client with continuous pulse oximetry who requires pharyngeal suctioning. D) The client who is pleasantly confused and requires assistance to the bathroom.

C) The client with continuous pulse oximetry who requires pharyngeal suctioning.

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

C) help the client achieve optimal levels of health.

Client with a high fever receiving intravenous fluids, antibiotics and oxygen

A client being treated for myasthenia gravis at home tells the nurse, "This medicine is so expensive. I have only been taking half of what the doctor ordered." How would the nurse most effectively meet this client's need?

Collaborate with other disciplines to determine the best way to meet the client's medication requirements.

A client in the last stages of pancreatic cancer tells the nurse, "I am tired of fighting. I am ready to die." What is the nurse's best action?

Collaborate with other disciplines to plan end-of-life care for the client.

Collaborate with other disciplines to revise the discharge plans.

The nurse is caring for a vegetarian who is suffering from iron deficiency anemia. The nutritional plan for a client with anemia calls for the client to increase consumption of animal protein. How will the nurse plan to meet this client's nutritional needs?

Collaborate with the nutritionist to modify the nutritional plan.

After instituting interventions to increase oxygenation, the client shows no signs of improvement. What is the nurse's priority action?

Communicate with the physician for additional orders.

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

Communicate with the physician for additional orders. Explanation: If the nurse's interventions have been ineffective, the physician must be notified of the client's deteriorating status. The physician can direct other medical interventions. Documenting the interventions does not take priority over the client's physiologic needs. Allowing another 30 minutes to elapse before taking action will only cause further deterioration in the client's status. The nurse should know the client's code status when taking over the client's care.

The nurse is caring for a client who is recovering from a cerebrovascular accident. When reviewing the client's orders, the nurse notes that one of the physicians wrote orders to ambulate the client, whereas another physician ordered strict bed rest for the client. How would the nurse most appropriately remedy this conflict? - Communicate with the physicians to coordinate their orders. - Instruct the client to ask the physicians for clarifications of instructions. - Collaborate with the physical therapist to determine the client's ability. - Assess the client to determine whether the client is capable of ambulation.

Communicate with the physicians to coordinate their orders. Explanation: As coordinator of care, the nurse is responsible for ensuring the continuity of the treatment plan. If conflicts occur in the treatment plan, the nurse should first consult with the physicians who have written the conflicting orders. The nurse may assess the client to determine whether the client is capable of ambulation, but this does not resolve the conflict or determine whether ambulation is in the client's best interest. It is not the client's responsibility to clarify nursing orders. Collaboration with the physical therapist could become part of the plan later, but the physicians' orders have to be clarified first.

A client on the medical-surgical unit is scheduled for several diagnostic tests. The nurse is concerned that the tests will be too tiring for the client. What would be the nurse's most appropriate action? - Coordinate with the other disciplines to schedule the tests with adequate rest for the client. - Coordinate with the other disciplines to determine if all the tests scheduled are necessary. - Instruct the client to refuse the diagnostic tests if the client becomes too fatigued. - Review the physician's progress notes to determine if any of the tests are not indicated.

Coordinate with the other disciplines to schedule the tests with adequate rest for the client. Explanation: The nurse's most appropriate course of action is to coordinate with the other disciplines to plan the scheduling of the tests with opportunities for the client to rest. Since the tests have been ordered by the physician, the other disciplines and the nurse cannot change the orders without the physician doing so. If the nurse feels that any of the tests are unnecessary, the appropriate course of action would be to consult with the ordering physician. While the client has the right to refuse any treatment, it would be more beneficial to the client if steps were taken earlier to prevent the necessity of the client's refusal.

Which statement by a nurse case manager regarding this nurse's role in client care is most accurate? • "Even though I do not provide care to clients, my work is very important." • "Moving away from client care is a necessary step to advancing my career." • "I provide a critical service that is necessary for financial reimbursement." • "I provide indirect care to my clients by coordinating their treatment with other disciplines."

Correct response: • "I provide indirect care to my clients by coordinating their treatment with other disciplines." Explanation: Nurses can provide direct, indirect, and collaborative care for their clients. A case manager directs interventions on behalf of the client away from the client's bedside. The most appropriate response is "I provide indirect care...". The case manager's response about the work being important does not adequately explain the role of the case manager. The case manager's role in facilitating financial reimbursement is critical, but does not address the nurse manager's role in client care. The case manager is still providing client care.

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? • "My wife's been gone for about 7 months now." • "I sort my medication into an organizer every week." • "My daughter has been staying with me the past few weeks." • "I asked my neighbors to help me with my yard work."

Correct response: • "My wife's been gone for about 7 months now." Explanation: The client's loss may be affecting how well the client is able to provide self-care. The client may be depressed and questioning the benefits of the health care regimen, or the client may have depended on the wife to help with health care and no longer has the ability to take care of himself. Assessment of the client allows the nurse to alter the plan of care to meet the client's needs. The statements concerning having a family member staying with the client, having help with the yard work, and sorting medications into an organizer all indicate factors that would improve the client's ability to provide self-care, not decrease it.

A client requires a change and reapplication of a colostomy bag. The nurse has never changed an ostomy bag before. What is the nurse's best course of action? • Ask the client how the bag is changed. • Determine the necessity of the bag change. • Read the policy and procedure manual. • Ask a skilled nurse to assist with the procedure.

Correct response: • Ask a skilled nurse to assist with the procedure. Explanation: Professional nurses should only undertake tasks that they have been properly trained to perform. Because the nurse has no experience in changing an ostomy bag, it would be most appropriate to have the assistance of an experienced nurse. It would be inappropriate to ask the client how the bag is changed. The client is relying on the nurse to have the necessary technical knowledge. Reading the policy and procedure manual alone would not ensure the successful completion of the procedure. The necessity of the ostomy bag change has already been established.

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? • Ask the surgeon to wait until the client has had a chance to talk to the spouse. • Inform the surgeon that the nurse will not sign the informed consent form. • Ask the client whether the client is afraid that the spouse will be angry. • Remind the client that the client is responsible for the client's own health care decisions.

Correct response: • Ask the surgeon to wait until the client has had a chance to talk to the spouse. Explanation: It is important to consider the client's wishes, so the nurse should advocate for the client and ask the surgeon to wait until the client has talked to the spouse. Telling the client that the client is responsible for the client's own health care decisions does not respect the client's desire to consult the spouse. The client has not expressed being fearful of the spouse. Informing the surgeon that the nurse will not sign the consent form will not satisfy the client's request.

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

Correct response: • Auscultating of bilateral lung sounds Explanation: Surveillance or monitoring nursing interventions include detecting changes from baseline data and recognizing abnormal responses. Nurses rely on the senses to detect changes: observing the appearance and characteristics of clients; hearing by auscultation, pitch, and tone; detecting odors and comparing them with past experience and knowledge of specific problems; and using touch to assess body temperature, skin condition, clamminess, or diaphoresis. Nurses use all of these surveillance or monitoring activities to determine the current status of clients and changes from previous states. Nurses often detect subtle changes in a client's condition and communicate them to the physician to minimize problems. Providing hygiene and administering a paracetamol tablet are examples of maintenance nursing interventions. Use of therapeutic communication skills is an example of a supportive nursing intervention.

Discharge plans for a client with a mental health disorder include living with family members. The nurse learns that the family is no longer willing to allow the client to live with them. What is the nurse's most appropriate action? • Inform the family that it is not possible to change the discharge plans. • Instruct the client to make alternate living arrangements. • Communicate with the physician about additional orders. • Collaborate with other disciplines to revise the discharge plans.

Correct response: • Collaborate with other disciplines to revise the discharge plans. Explanation: The discharge needs of this client are complicated, and the nurse will need the assistance of other disciplines to make a successful discharge plan. The client should have input into the future living arrangements, but the client does not have the resources to make the arrangements alone. The physician may be involved in the discharge plan, but additional orders are not necessary. It is not true (and would be inappropriate) to tell the family that discharge plans cannot be changed. If the family is unwilling to take the client, the placement will be unsuccessful.

The nurse is caring for a client who is recovering from a cerebrovascular accident. When reviewing the client's orders, the nurse notes that one of the physicians wrote orders to ambulate the client, whereas another physician ordered strict bed rest for the client. How would the nurse most appropriately remedy this conflict? • Collaborate with the physical therapist to determine the client's ability. • Assess the client to determine whether the client is capable of ambulation. • Communicate with the physicians to coordinate their orders. • Instruct the client to ask the physicians for clarifications of instructions.

Correct response: • Communicate with the physicians to coordinate their orders. Explanation: As coordinator of care, the nurse is responsible for ensuring the continuity of the treatment plan. If conflicts occur in the treatment plan, the nurse should first consult with the physicians who have written the conflicting orders. The nurse may assess the client to determine whether the client is capable of ambulation, but this does not resolve the conflict or determine whether ambulation is in the client's best interest. It is not the client's responsibility to clarify nursing orders. Collaboration with the physical therapist could become part of the plan later, but the physicians' orders have to be clarified first.

A client on the medical-surgical unit is scheduled for several diagnostic tests. The nurse is concerned that the tests will be too tiring for the client. What would be the nurse's mostappropriate action? • Instruct the client to refuse the diagnostic tests if the client becomes too fatigued. • Review the physician's progress notes to determine if any of the tests are not indicated. • Coordinate with the other disciplines to determine if all the tests scheduled are necessary. • Coordinate with the other disciplines to schedule the tests with adequate rest for the client.

Correct response: • Coordinate with the other disciplines to schedule the tests with adequate rest for the client. Explanation: The nurse's most appropriate course of action is to coordinate with the other disciplines to plan the scheduling of the tests with opportunities for the client to rest. Since the tests have been ordered by the physician, the other disciplines and the nurse cannot change the orders without the physician doing so. If the nurse feels that any of the tests are unnecessary, the appropriate course of action would be to consult with the ordering physician. While the client has the right to refuse any treatment, it would be more beneficial to the client if steps were taken earlier to prevent the necessity of the client's refusal.

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? • Arrange with the nurse case manager for an early discharge. • Encourage the client to provide as much self-care as possible. • Teach the family to anticipate the client's needs to care for the client. Perform all care activities for the client to facilitate rest.

Correct response: • Encourage the client to provide as much self-care as possible. Explanation: The nurse must encourage the client to provide as much self-care as possible in order to achieve the highest level of independence. Performing all care activities for the client makes the client dependent on the nurse. If the family anticipates and meets all the client's needs, this also hinders the client's recovery. An early discharge is not indicated because the client must be sufficiently recovered.

The nurse in a burn intensive care unit (BICU) is caring for a 3-year-old child who was burned with scalding hot water. The client has burns covering 75% of the body. The client's condition is critical but stable. At 1000, the nurse reassesses the client and finds that the client is agitated and pulling at the endotracheal tube. Which is the nurse's priority intervention for this client at this time? • Ensuring that the endotracheal tube is secure • Providing medication for agitation • Repositioning to prevent pressure injuries • Changing the dressing to prevent infection

Correct response: • Ensuring that the endotracheal tube is secure Explanation: The ABCs (airway, breathing, and circulation) are always top priority in client care. In this example, ensuring that the client maintains a patent airway will always be top priority. Each of these nursing tasks is important and will need to be accomplished at some point during client care.

Which action should the nurse take to ensure that an unlicensed assistive personnel (UAP) understands the instructions to perform a delegated task? • Inform the UAP of the importance of following each step listed in the procedure manual. • Request that the UAP place the steps of the task in the framework of the nursing process. • Instruct the UAP to repeat the instructions to be sure the nurse has communicated clearly. • Ask another UAP to observe and assist the UAP in performing the task.

Correct response: • Instruct the UAP to repeat the instructions to be sure the nurse has communicated clearly. Explanation: Instruct the UAP to repeat the nurse's instructions to be sure the nurse has communicated them clearly. The UAP must be clear on the difference between nursing tasks and the nursing process, as the nursing process structures care delivered by the registered nurse. Although it is important for the UAP to follow procedure manuals, it is important that the registered nurse is clear on the UAP's understanding of the steps through direct observation or discussions. It is not correct to ask another UAP to observe and assist the UAP in performing the task.

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? • Initiate an intravenous line and administer 500mL of normal saline. • DIscuss the need to change positions slowly, especially when moving from sitting to standing. • Perform vital signs and blood glucose level. • Perform a full review of systems.

Correct response: • Perform vital signs and blood glucose level. Explanation: A patient who presents with severe dizziness needs a comprehensive assessment, including vital signs and blood glucose level, prior to any other action. The results of the assessment could help determine which actions to take next. Discussing the need to change positions slowly and home blood pressure monitoring may be appropriate educational activities for this client, but the assessment should be performed first to be sure that the client's symptoms are caused by hypotension. The client may also need intravenous fluids to help correct hypotension, but the client must be assessed first.

Which task would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? • Retrieve a unit of blood from the blood bank. • Reassess the client's sacrum for redness when doing a bed bath. • Secure the client's jewelry before surgery. • Provide the client with assistance in transferring to the bedside commode.

Correct response: • Provide the client with assistance in transferring to the bedside commode. Explanation: Assisting with toileting is one of the tasks the state board of nursing permits UAPs to perform. UAPs commonly performed this task in health facilities. Each of the other responses demands a level of responsibility that the nurse cannot legally delegate to a UAP.

An indwelling urinary catheter has been ordered for a client experiencing urinary retention after surgery. When the nurse enters the room to place the catheter, the client reports voiding in the bathroom. Which is the nurse's most appropriate action? • Reassess whether the client still needs the urinary catheter. • Inform the client that the catheter will no longer be necessary. • Insert the urinary catheter as ordered to relieve the urinary retention. • Instruct the client that the catheter is essential to check for urinary retention.

Correct response: • Reassess whether the client still needs the urinary catheter. Explanation: Before any intervention is implemented, the nurse should assess whether the intervention is still indicated. In this case, the client's report of voiding makes it all the more essential that the nurse assess whether the client is still retaining urine before inserting the catheter. The nurse should not tell the client the catheter is necessary or unnecessary until after the nurse has completed the assessment and confirmed whether it is necessary.

A client with hypertension being seen for follow-up care has a blood pressure of 160/100 mm Hg. The client reports following the treatment regimen closely and that blood pressure readings have been elevated for the last 2 weeks. What is the nurse's most appropriate action? • Interview the family to determine if the client is giving accurate information. • Inform the client that the blood pressure medication will have to be changed. • Reinforce the instructions for the treatment regimen to the client. • Report the findings to the physician for further plans.

Correct response: • Report the findings to the physician for further plans. Explanation: The nurse should report the findings to the physician so that the treatment regimen can be revised. The client reports following the treatment regimen, so reinforcing the instructions is not indicated. Interviewing the family would indicate to the client that the nurse did not trust the client's report, so this would be inappropriate. The nurse cannot tell the client that the blood pressure medication will have to be changed because that is the physician's decision.

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? • Consult with the physical therapist to determine the client's ability. • Continue assisting the client to the bathroom to ensure the client's safety. • Revise the care plan to allow the client to ambulate to the bathroom independently. • Instruct the client's family to assist the client to ambulate to the bathroom.

Correct response: • Revise the care plan to allow the client to ambulate to the bathroom independently. Explanation: The intervention of assisting the client to the bathroom is no longer indicated, so the nurse would appropriately revise the care plan to discontinue that intervention. A consult with a physical therapist is not necessary to verify the nurse's independent assessment. If the client is safe to ambulate to the restroom independently, it is not necessary for the family to assist.

A new unlicensed assistive personnel (UAP) is preparing to ambulate an obese client. The registered nurse (RN) is concerned about the UAP's ability to safely ambulate the client. Which would be the nurse's most appropriate action? • Tell the UAP not to ambulate the client at this time. • Tell the UAP to ask the client whether the client is comfortable with the UAP assisting ambulation. • Tell the UAP that a different UAP should ambulate the client. • Tell the UAP that the RN will assist the UAP with the client's ambulation.

Correct response: • Tell the UAP that the RN will assist the UAP with the client's ambulation. Explanation: The client's safety is always the nurse's primary concern. If the nurse believes that the UAP is unable to safely ambulate the client at this time, the nurse could offer assistance. By assisting the UAP, the nurse ensures the client's safety while still allowing the new UAP to learn. Having a different UAP ambulate the client or instructing the UAP not to ambulate the client does not assist the UAP in learning. Asking the client whether the client feels comfortable having the UAP ambulate the client is inappropriate.

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 mostappropriate course of action? • The nurse should recognize the necessity of the assignment and provide care to the best of the nurse's ability. • The nurse should inform the charge nurse that the nurse does not have the experience to properly care for this client. • The nurse should ask another nurse who was previously assigned to the client for instruction. • The nurse should request that the blood transfusions be delayed until the next shift.

Correct response: • The nurse should inform the charge nurse that the nurse does not have the experience to properly care for this client. Explanation: The nurse should recognize that the nurse lacks the competence to safely care for a client with these complex needs and inform the charge nurse of the fact. This assignment would be an inappropriate delegation on the part of the charge nurse and could cause injury to the client. The other options do not take the safety of the client into consideration.

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 parents verbalize acceptance of the need to closely monitor their child's condition. C) The parents have comprehensive insurance coverage for their family's medical care. D) The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years.

D) The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years.

Delay the instruction until the visitors leave. The nurse must take into consideration the client's developmental level and willingness to participate in care in order to successfully implement the plan of care. The client is a teenager and socialization with a peer group is essential, so the nurse would most appropriately wait until the visitors leave. Telling the visitors to leave in 10 minutes might upset the client and hinder the education. Simply asking if the client has questions does not appropriately educate the client. Leaving written information does not ensure that the client will read or understand the information.

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? - Give the visitors instructions to leave in 10 minutes. - Delay the instruction until the visitors leave. - Ask the client if the client has any questions. - Leave written information for the client to read later.

Delay the instruction until the visitors leave. Explanation: The nurse must take into consideration the client's developmental level and willingness to participate in care in order to successfully implement the plan of care. The client is a teenager and socialization with a peer group is essential, so the nurse would most appropriately wait until the visitors leave. Telling the visitors to leave in 10 minutes might upset the client and hinder the education. Simply asking if the client has questions does not appropriately educate the client. Leaving written information does not ensure that the client will read or understand the information.

A nurse is preparing to educate a client about self-care after a cataract surgery. Which of the following would the nurse do first?

Determine the client's willingness to follow the regimen.

A nurse is preparing to educate a client about self-care after cataract surgery. Which of the following would the nurse do first?

Determine the client's willingness to follow the regimen.

A nurse is preparing to educate a client about self-care after cataract surgery. Which should the nurse do first? - Identify changes from the baseline. - Determine the client's willingness to follow the regimen. - Ensure physician approval for the education plan. - Instruct the unlicensed assistive personnel on what to teach the client.

Determine the client's willingness to follow the regimen. Explanation: The prerequisite to health education about self-care after cataract surgery is the client's willingness to follow the regimen. Once a nurse is aware of the client's readiness for learning, the nurse can implement outcome-based education plans. Identifying changes from baseline is important for monitoring interventions. Approval by the physician may not be necessary. Delegating the teaching activity to an unlicensed assistive personnel is inappropriate because it is not within the person's scope of practice.

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?

Discuss possible alternatives to a blood transfusion with the physician. As coordinator of the client's care, the nurse functions as an intermediary between the physician and the client. In order to honor the client's wishes, the nurse would most appropriately consult with the physician to meet the client's physical needs, as well as the client's spiritual needs. The risk and benefits of a blood transfusion are not the relevant issue with the client. Discussing the client's options with other church members would violate the client's privacy and would not meet the client's physical needs. It might be advisable to discuss the client's refusal of care with the hospital risk manager to protect the legal requirements of the institution, but it is not the priority.

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? - Discuss the client's refusal with hospital risk managers. - Discuss the risks and benefits of a blood transfusion with the client. - Discuss the client's options with other church members. - Discuss possible alternatives to a blood transfusion with the physician.

Discuss possible alternatives to a blood transfusion with the physician. Explanation: As coordinator of the client's care, the nurse functions as an intermediary between the physician and the client. In order to honor the client's wishes, the nurse would most appropriately consult with the physician to meet the client's physical needs, as well as the client's spiritual needs. The risk and benefits of a blood transfusion are not the relevant issue with the client. Discussing the client's options with other church members would violate the client's privacy and would not meet the client's physical needs. It might be advisable to discuss the client's refusal of care with the hospital risk manager to protect the legal requirements of the institution, but it is not the priority.

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?

Discuss with the client the reasons for declining surgery. The nurse needs further information before deciding what interventions are necessary, so the most appropriate action is to determine the client's reasons for refusal. Until the information is collected, the nurse cannot decide whether reviewing the risks and benefits of surgery would be effective. It is also premature to ask the client to discuss the decision with family members. It is not appropriate to notify the physician until the assessment is complete.

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? - Review with the client the risks and benefits of surgery. - Notify the physician of the client's refusal. - Ask the client to discuss the decision with family members. - Discuss with the client the reasons for declining surgery.

Discuss with the client the reasons for declining surgery. Explanation: The nurse needs further information before deciding what interventions are necessary, so the most appropriate action is to determine the client's reasons for refusal. Until the information is collected, the nurse cannot decide whether reviewing the risks and benefits of surgery would be effective. It is also premature to ask the client to discuss the decision with family members. It is not appropriate to notify the physician until the assessment is complete.

Which is the priority question for the nurse to consider before implementing a new intervention?

Does this treatment make sense for this client? All of these questions are important, but the priority is whether the treatment makes sense for the client. If not, answering the other questions is unnecessary.

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

Does this treatment make sense for this client? Explanation: All of these questions are important, but the priority is whether the treatment makes sense for the client. If not, answering the other questions is unnecessary.

Which of the following is a nursing intervention that facilitates life span care?

Educate family members about normal growth and development patter

Which of the following is a nursing intervention that facilitates life span care?

Educate family members about normal growth and development patterns.

The nurse has administered pain medication to a client with a fractured femur. One hour later, the client reports relief of pain. What parameters would the nurse document to support evaluation of pain management?

Effectiveness of intervention including current pain scale, time frame, and client self-report. Because the client has reported the effectiveness of the intervention, the next step in implementation is to correctly complete the documentation including client's self-reporting of current pain descriptives, pain scale rating, and how effective interventions have been. Pain medication has not been decreased so this would not support interventions. Likewise, the client has experienced relief so documenting length of time between requests is not what is required at this time. Alternative pain management modalities are not the focus so this would not be appropriate.

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?

Encourage the client to provide as much self-care as possible.

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? - Teach the family to anticipate the client's needs to care for the client. - Perform all care activities for the client to facilitate rest. - Encourage the client to provide as much self-care as possible. - Arrange with the nurse case manager for an early discharge.

Encourage the client to provide as much self-care as possible. Explanation: The nurse must encourage the client to provide as much self-care as possible in order to achieve the highest level of independence. Performing all care activities for the client makes the client dependent on the nurse. If the family anticipates and meets all the client's needs, this also hinders the client's recovery. An early discharge is not indicated because the client must be sufficiently recovered.

The nurse in a burn intensive care unit (BICU) is caring for a 3-year-old child who was burned with scalding hot water. The client has burns covering 75% of the body. The client's condition is critical but stable. At 1000, the nurse reassesses the client and finds that the client is agitated and pulling at the endotracheal tube. Which is the nurse's priority intervention for this client at this time? - Ensuring that the endotracheal tube is secure - Repositioning to prevent pressure injuries - Providing medication for agitation - Changing the dressing to prevent infection

Ensuring that the endotracheal tube is secure Explanation: The ABCs (airway, breathing, and circulation) are always top priority in client care. In this example, ensuring that the client maintains a patent airway will always be top priority. Each of these nursing tasks is important and will need to be accomplished at some point during client care.

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. Which has the nurse failed to organize?

Equipment and personnel

A nurse is catheterizing a client. Which scenario demonstrates steps the nurse would take to ensure client respect and privacy? - Explain the procedure to the client, close the door to the room, and cover all areas of the client, only exposing the area for catheterization. - Bring in another nurse to provide support and prevent questionable behaviors, explain the procedure to the client, and close the door and privacy curtain prior to beginning the procedure. - Verify the client's identifiable information, explain the procedure to the family, and pull the privacy curtain to allow the client to feel comfortable in having family close by. - Ask family members to leave the room briefly, close the door, and ask the client if he or she would like a sheet to cover oneself.

Explain the procedure to the client, close the door to the room, and cover all areas of the client, only exposing the area for catheterization. Explanation: It is important to think about the environment for each intervention. Pay special attention to respecting the client's privacy and dignity; for example, close the door to the room or pull the drapes between the beds. To demonstrate respect, the procedure should be explained to the client and all areas except the sterile area should be covered to protect modesty and privacy. Asking another nurse to assist is helpful, but not required and may make the client feel awkward. There is not need to discuss with the family, because the client does not have any cognitive issues.

The nurse is discussing dietary options with a client who is upset due to the inability of not being able to have foods 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?" What is the purpose for giving the client an option?

Giving the client options demonstrates active participation in care

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? - Medicate the client with the ordered pain medication. - Instruct the client in nonpharmacologic pain management. - Go to the client and assess the client's pain. - Determine the frequency of pain medication.

Go to the client and assess the client's pain. Explanation: The nurse's first action should always be to determine the cause of the client's pain in order to determine the correct intervention. After determining the cause, the nurse can plan how to proceed. The other steps would be appropriate, but only after the assessment.

Nurses perform many independent nursing actions when caring for clients. Which action is considered an independent (nurse-initiated) action?

Helping to allay a client's fears about surgery

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

Helping to allay a client's fears about surgery Explanation: An independent (nurse-initiated) action is one that a nurse may initiate and carry out independently, without an order from a physician or any other health care provider. Helping the client decrease fear about surgery by answering questions or arranging a meeting with the surgeon is an independent nursing intervention. Interventions that involve executing a physician's orders, such as for catheterization and medication administration, are dependent nursing interventions. Meeting with other health care professionals describes collaborative care.

A client is diagnosed with hypertension and placed on a low sodium diet and given smoking cessation literature. The nurse observes the client eating from a fast food restaraunt 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 patient?

Identify what barriers the client feels are preventing adherence with the plan.

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 restaraunt 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. Identify what barriers the client feels are preventing adherence with the plan. c. Collaborate with other health care professionals about the client's treatment. d. Change the nursing care plan.

Identify what barriers the client feels are preventing adherence with the plan. The nurse must first identify why the client is not following the therapy before collaboration with other health care professionals or a change in the nursing care plan can be initiated. Simply explaining the effects of a high-salt diet and smoking on the blood pressure may not address the underlying cause of why the client is choosing not to follow the recommended care.

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 restaraunt 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? - Change the nursing care plan. - Explain the effects of a high-salt diet and smoking on blood pressure. - Collaborate with other health care professionals about the client's treatment. - Identify what barriers the client feels are preventing adherence with the plan.

Identify what barriers the client feels are preventing adherence with the plan. Explanation: The nurse must first identify why the client is not following the therapy before collaboration with other health care professionals or a change in the nursing care plan can be initiated. Simply explaining the effects of a high-salt diet and smoking on the blood pressure may not address the underlying cause of why the client is choosing not to follow the recommended care.

As the nurse bathes a client, she notes his skin color and integrity, his ability to respond to simple directions, and his muscle tone. Which statement best explains why such continuing data collection is so important?

It enables the nurse to revise the care plan appropriately.

As the nurse bathes a patient, she notes his skin color and integrity, his ability to respond to simple directions, and his muscle tone. Which statement best explains why such continuing data collection is so important?

It enables the nurse to revise the care plan appropriately.

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?

Make changes in the plan of care based upon assessment data.

Question 4 See full question 1m 21s The physician has ordered that the client should ambulate 3 times a day. The nurse enters the room to ambulate the client and the client reports pain. What is the nurse's most appropriate action?

Medicate the client and wait to ambulate later. It is most appropriate to manage the client's pain first.

The physician has ordered that the client should ambulate 3 times a day. The nurse enters the room to ambulate the client and the client reports pain. What is the nurse's most appropriate action?

Medicate the client and wait to ambulate later.

The physician has ordered that the client should ambulate 3 times a day. The nurse enters the room to ambulate the client and the client reports pain. What is the nurse's most appropriate action? - Ambulate the client and medicate later. - Emphasize to the client the importance of following the treatment plan. - Explain to the client the benefits of ambulation. - Medicate the client and wait to ambulate later.

Medicate the client and wait to ambulate later. Explanation: It is most appropriate to manage the client's pain first. The client will be able to ambulate more easily and it is not necessary to cause the client further pain. Ambulating first considers the needs of the nurse, not the client. The client has not indicated misunderstanding of benefits or the importance of ambulation.

Which nursing action would be most effective in helping a client learn self-care behaviors? - Model self-care behaviors for the client. - Ask client to discuss the client's goals for the day at the start of the shift. - Collect data on the number of self-care activities the client has performed that day. - Check with the client to ensure that personal self-care goals are being met.

Model self-care behaviors for the client. Explanation: Modeling self-care behaviors is a nursing intervention and is the action most effective in helping the client learn the self-care behaviors. The other answer options refer to evaluation of the client's response to interventions related to learning self-care behaviors.

The nurse is assigned a client who had an uneventful colon resection two days ago and requires a dressing change. To which nursing team member should the nurse avoid delegating the dressing change?

Nursing assistant

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? - Process - Structure - Outcome - Cost-effectiveness

Outcome Explanation: Outcome evaluation focuses on measurable changes in the health status of the client or the end results of nursing care, such as an expedited discharge of the client based on the client recovering more quickly due to an intervention. The focus of a process evaluation is the nature and sequence of activities carried out by nurses implementing the nursing process. A structure evaluation or audit focuses on the environment in which care is provided. Cost-effectiveness is not a type of evaluation identified by the American Nurses Association.

The nurse is caring for Mr. M., a 48-year-old man with congestive heart failure. The nurse manager informs the nurse that Mr. M. 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?

Outcome evaluation

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? - Discuss the need to change positions slowly, especially when moving from sitting to standing. - Initiate an intravenous line and administer 500mL of normal saline. - Perform a full review of systems. - Perform vital signs and blood glucose level.

Perform vital signs and blood glucose level. Explanation: A patient who presents with severe dizziness needs a comprehensive assessment, including vital signs and blood glucose level, prior to any other action. The results of the assessment could help determine which actions to take next. Discussing the need to change positions slowly and home blood pressure monitoring may be appropriate educational activities for this client, but the assessment should be performed first to be sure that the client's symptoms are caused by hypotension. The client may also need intravenous fluids to help correct hypotension, but the client must be assessed first.

The emergency room has a strict protocol regarding IM (intramuscular) injection technique. A nurse working in the emergency room has learned of a new technique to decrease pain with IM injections and would like to use it. What is the most appropriate way for the nurse to implement the technique?

Petition to change the protocol based on the new evidence.

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?

Praise the client for taking an active role in his care.

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? - Praise the client for taking an active role in the client's care. - Tell the client that gloves are required for this procedure. - Reassure the client that the nurse knows when to perform hand hygiene. - Inform the client that it is not necessary to wash hands before vital signs.

Praise the client for taking an active role in the client's care. Explanation: Clients should be empowered to take responsibility for self-care. All clients should be taught that they have the power to question any part of their care. The nurse would appropriately praise the client. It is necessary to wash hands before taking vital signs; gloves are not required for the procedure. Telling the client that the nurse knows when to perform hand hygiene is disrespectful of the client's concern.

The nurse is to delegate certain tasks to unlicensed assistive personnel (UAP). Which of the following tasks can be appropriately assigned to a UAP?

Provide client assistance to the bedside commode.

The nurse is to delegate certain tasks to unlicensed assistive personnel (UAP). Which of the following tasks can be appropriately assigned to a UAP?

Provide client assistance to the bedside commode. Assisting with toileting is one of the tasks permitted by the state board of nursing for UAP. This task is commonly performed by UAP in health facilities.

Which task would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? - Reassess the client's sacrum for redness when doing a bed bath. - Secure the client's jewelry before surgery. - Retrieve a unit of blood from the blood bank. - Provide the client with assistance in transferring to the bedside commode.

Provide the client with assistance in transferring to the bedside commode. Explanation: Assisting with toileting is one of the tasks the state board of nursing permits UAPs to perform. UAPs commonly performed this task in health facilities. Each of the other responses demands a level of responsibility that the nurse cannot legally delegate to a UAP.

Psychosocial background Explanation: The nurse is demonstrating an awareness of the client's psychosocial background, which includes consideration of the client's socioeconomic status. Research findings and current standards of care are examples of nursing variables. Developmental stage is a client variable that addresses the developmental needs of a client.

Reassess if the urinary catheter is still necessary for the client.

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? - Report the client's inability to learn to the case manager. - Reassess the appropriateness of the method of instruction. - Revise the plan to include the inclusion of a support group. - Teach the content again utilizing the same method.

Reassess the appropriateness of the method of instruction. Explanation: It is the nurse's responsibility to revise the plan of care if an intervention is not successful. The most appropriate action of the nurse would be to determine if the initial education was the most effective for this client. Simply teaching the content again without reassessing the client's needs would not necessarily be effective. A support group might be helpful, but not until the client's needs are evaluated. The case manager is not responsible for the client's learning.

Reassess the client to determine the effectiveness of the interventions. Explanation: After implementing any interventions (such as pain medication or any nonpharmacological pain control method, such as splinting the incision), the nurse must always reassess the client to determine the effectiveness of the interventions. It is more likely that the pain medication is available on an as-needed basis rather than at regular intervals; in any case, informing the client of the availability of pain medication is of lower priority than reassessing the client to determine the effectiveness of the interventions performed. There is no need to inform the physician that the client has required pain medication; the physician anticipated the client needing pain medication, which is why the physician ordered the medication for the client to begin with. After evaluating the effectiveness of the implemented interventions, if the nurse finds that they have been ineffective, then the nurse would then revise the plan and include additional interventions, including, possibly, other nonpharmacological pain interventions.

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

Reassess the client to determine whether the action is needed. Explanation: Although being prepared with the necessary equipment and checking with the client to make sure that the client is physically and psychologically ready for the intervention are important, it is crucial to reassess the client to determine whether the action is still needed before implementing any nursing intervention. Recording the intervention occurs after the nurse has completed the intervention.

A nurse in the ICU (intensive care unit) has been assigned to care for a client who was seriously injured during a gang rape. The nurse was raped 6 months ago and feels that she will be too upset to care for the client properly. How should the nurse deal with the assignment?

Recognize her limitations and ask for another nurse to be assigned.

The nurse is preparing to give the client a bath early in the morning. The client states, "I prefer to take my bath at night. It helps me sleep." What is the nurse's most appropriate action?

Reschedule the client's bath to the evening shift.

Risk factors for and prevention of diabetes mellitus An important nursing function is to enable clients to prevent illness. Because a member of the family has developed diabetes, the other family members are also at risk. The nurse would most appropriately educate the family about the risk factors for and prevention of diabetes mellitus. Knowledge of the medications used to treat diabetes is not necessary at this time and does not help meet the family's needs. The severity of the client's disease does not have an impact on the family's health. Knowledge of the cellular metabolism of glucose is not necessary for the family's health.

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? - Medications used to treat diabetes mellitus - The severity of the client's disease - Risk factors for and prevention of diabetes mellitus - The cellular metabolism of glucose

Risk factors for and prevention of diabetes mellitus Explanation: An important nursing function is to enable clients to prevent illness. Because a member of the family has developed diabetes, the other family members are also at risk. The nurse would most appropriately educate the family about the risk factors for and prevention of diabetes mellitus. Knowledge of the medications used to treat diabetes is not necessary at this time and does not help meet the family's needs. The severity of the client's disease does not have an impact on the family's health. Knowledge of the cellular metabolism of glucose is not necessary for the family's health.

Which role is a responsibility of the nurse in the nurse-health care team relationship? Select all that apply.

Serve as a liaison between the client and family and the health care team. Coordinate the inputs of the multidisciplinary team into a comprehensive plan of care.

The nurse is caring for a postoperative client who is receiving morphine sulfate for pain management. The nurse obtains the following vital signs. HR 74 RR 8 BP 114/68. After reviewing the nursing care plan and physician orders, the nurse administers naloxone (Narcan). What would allow the nurse to initiate this action?

Standing orders

The nurse is caring for a postoperative client who is receiving morphine sulfate for pain management. The nurse obtains the following vital signs: HR 74, RR 8, BP 114/68. After reviewing the nursing care plan and physician orders, the nurse administers naloxone. What would allow the nurse to initiate this action?

Standing orders

The nurse is caring for a postoperative client who is receiving morphine sulfate for pain management. The nurse obtains the following vital signs: heart rate, 74 beats/min; respiratory rate, 8 breaths/min; blood pressure, 114/68 mm Hg. After reviewing the nursing care plan and physician orders, the nurse administers naloxone. Which would allow the nurse to initiate this action? - Order set - Algorithm - Standing orders - Protocol

Standing orders Explanation: Standing orders allow the nurse to initiate actions that ordinarily require the order of a physician, such as administering naloxone. An algorithm is a binary decision tree that guides stepwise assessment and intervention for a high-risk subgroup of clients. A protocol is a written plan that details nursing activities to be executed in specific situations. An order set is a preprinted set of provider orders that expedite the provider order process.

Mr. J. is a 56-year-old man status post admission for a myocardial infarction and coronary artery bypass graft. He is preparing to go home tomorrow. Mr. J. expresses that he feels unprepared to cook heart-healthy foods. The nurse sits with Mr. J. and reviews the heart-healthy nutrition plan, asking him to identify which foods would be appropriate for him to eat. What type of nursing intervention is the nurse engaging in?

Supervisory intervention

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?

Surveillance

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? - Educational - Psychomotor - Surveillance - Maintenance

Surveillance Explanation: Surveillance interventions include detecting changes from baseline data and recognizing abnormal response. Nurses rely on the senses to detect changes, such as observing the appearance and characteristics of clients and hearing by auscultation, pitch, and tone. Nurses use these surveillance activities to determine the current status of clients and changes from previous states. Educational interventions require instruction, demonstration, and return demonstration of knowledge or a skill set. Psychomotor interventions involve the nurse physically working with the client. Maintenance interventions involve the nurse assisting the client with performing routine activities of daily living.

Nurse Mayweather is auscultating lung sounds. She notes crackles in the LLL which were not present at the start of the shift. Nurse Mayweather is engaged in which type of nursing intervention?

Surveillance intervention

Nurse Mayweather is auscultating lung sounds. She notes crackles in the LLL which were not present at the start of the shift. Nurse Mayweather is engaged in which type of nursing intervention?

Surveillance intervention Surveillance interventions include detecting changes from baseline data and recognizing abnormal response. Nurses rely on the senses to detect changes: observing the appearance and characteristics of clients; hearing by auscultation, pitch, and tone

The client reports right knee pain of 6/10 on the pain scale and requests for medication. The nurse assesses and flushes the IV site. Which type of intervention skill is the nurse using?

Technical skill Technical skills are used to carry out treatments and procedures. Nurses learn the specific skills through clinical practice. Technical competence means being able to use equipment, machines, and supplies in a particular specialty.

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?

The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years.

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? - The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years. - The parents have comprehensive insurance coverage for their family's medical care. - The parents verbalize acceptance of the need to closely monitor their child's condition. - The client expresses a desire to learn how to manage the medication regime.

The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years. Explanation: If the family has experience caring for a child with a seizure disorder, the family would already have some basic knowledge, so the nurse would address the education differently. The client expressing a desire to learn indicates receptiveness to the education. The parents' acceptance of their child's condition indicates that they are ready to begin dealing with the child's condition. The fact that the child has comprehensive insurance coverage is a strength that will make options available to the family, but will not necessarily change the nurse's educational plan.

The nurse is planning instruction on wound care to an adult client. What variables would cause the nurse to alter the education plan? Select all that apply.

The client is blind. The client denies the need for education.

The client has a diagnosis of Risk for Injury related to falls. How would the nurse know if the intervention was successful? - The client is free of falls. - The client verbalizes risks for injury. - The client is taught safety precautions. - The client calls for assistance to get out of bed.

The client is free of falls. Explanation: Interventions for risk diagnoses are directed at prevention. The most appropriate way to evaluate the success of the interventions is to determine if the risk was prevented. The best evaluation criteria would be if the client remained free of falls. The client calling for assistance might prevent a fall, but does not signify that a fall will not occur. Teaching clients safety precautions and having the client verbalize risk for injuries is important but does not necessarily mean that an injury is prevented.

What assessment data would indicate to the nurse at the conclusion of an education session that the client education was effective? Select all that apply.

The client verbalizes understanding of the instructions. The client is able to answer the nurse's questions. The client discusses the specifics of what was taught during the session. After an intervention is implemented, the nurse must assess the effectiveness of the intervention. The client stating an understanding of the instructions gives the nurse an indication that learning has taken place. Asking the client questions and receiving the correct answers is an excellent way to judge the client's knowledge. The client asking for the nurse to repeat the instructions shows that the client does not have a clear understanding. The client's statement that the spouse will handle the care signals that the client is not ready to learn at this time. The client's ability to discuss the specifics of the material suggests that learning has taken place.

The client's respiratory rate decreases. The client states, "I can breathe easier now." The client's oxygen saturation level increases.

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?

The nurse encourages the client to participate in all treatment decisions as the center of the health care team. TJC encourages clients to become active, involved, and informed participants on the health care team. By becoming involved and "speaking up" research shows that clients who take part in decisions about their health care are more likely to have better outcomes. The nurse should never want to prevent client questions. While clients are encouraged to be independent, trusted family members and friends can be an asset to the client's care. The nurse should investigate the possibility of an error if the client questions the nurse about a medication.

When caring for a client in the emergency room who has presented with symptoms of a (MI) myocardial infarction, the nurse orders laboratory tests and administers medication to the client before the physician has examined the client. In order for the nurse to be operating within the nurse's scope of practice, what conditions must be present?

The nurse is operating under standing orders for clients with MIs.

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? - The nurse should recognize the necessity of the assignment and provide care to the best of the nurse's ability. - The nurse should inform the charge nurse that the nurse does not have the experience to properly care for this client. - The nurse should ask another nurse who was previously assigned to the client for instruction. - The nurse should request that the blood transfusions be delayed until the next shift.

The nurse should inform the charge nurse that the nurse does not have the experience to properly care for this client. Explanation: The nurse should recognize that the nurse lacks the competence to safely care for a client with these complex needs and inform the charge nurse of the fact. This assignment would be an inappropriate delegation on the part of the charge nurse and could cause injury to the client. The other options do not take the safety of the client into consideration.

The nurse is planning to give a new medication to a client. When administering the medication, what is the nurse's most appropriate step to ensure client safety?

The nurse should know what side effects are possible from this medication.

Which type of nursing intervention is oxygen administration and why is it considered to be so? a. A dependent nursing intervention, because oxygen is considered a drug that requires a physician's order b. A collaborative nursing intervention, because it is ordered by the respiratory therapist c. An independent nursing intervention, because nurses have the necessary skill to administer oxygen d. An interdependent intervention, because physicians, nurses, and respiratory therapists have the necessary skill to administer oxygen

a. A dependent nursing intervention, because oxygen is considered a drug that requires a physician's order Oxygen administration is a dependent nursing intervention because it requires a physician's order. Independent nursing interventions are autonomous actions based on scientific rationale that a nurse executes to benefit the client in a predictable way related to the nursing diagnosis and expected outcomes. Nursing-initiated interventions, such as teaching, providing fluids, and assisting with guided imagery, do not require a physician's order. Collaborative and interdependent are not types of nursing interventions.

Which examples of nursing actions involve direct care of the client? Select all that apply. a. A nurse counsels a young family who is interested in natural family planning. b. A nurse massages the back of a client while performing a skin assessment. c. A nurse arranges for a consultation for a client who has no health insurance. d. A nurse helps a client in hospice fill out a living will form. e. A nurse arranges for physical therapy for a client who had a stroke.

a. A nurse counsels a young family who is interested in natural family planning. b. A nurse massages the back of a client while performing a skin assessment. d. A nurse helps a client in hospice fill out a living will form. A direct care intervention is a treatment performed through interaction with the client(s). Direct care interventions include both physiologic and psychosocial nursing actions, and include both the "laying of hands" actions and those that are more supportive and counseling in nature. An indirect care intervention is a treatment performed away from the client but on behalf of a client or group of clients. Indirect care interventions include nursing actions aimed at management of the client care environment and interdisciplinary collaboration.

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

a. Administering a glycerin suppository to a constipated client who has not responded to oral stool softeners Standing orders and protocols often surround the management of bowel elimination. Modification of a client's IV fluid or administration of a new antihypertensive are client-specific interventions that are physician initiated. The care team cannot independently change a client's advance directive.

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

a. Assess the client to determine the cause of the pain. One hour after administering pain medication, the nurse would expect the client to be relieved of pain. A new report of intense pain might signal a complication and requires a thorough assessment. The nurse might request an order for additional pain medication, but only after a thorough assessment. Telling the client how often medication can be received does not help relieve the client's pain. Repositioning and splinting the incision are interventions that the nurse might perform, but only after determining the cause of the pain.

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. Assess the client's blood pressure to determine if the medication is indicated. b. Determine the client's reaction to the medication in the past. c. Ask the client to verbalize the purpose of the medication. d. Tell the client to report any side effects experienced.

a. Assess the client's blood pressure to determine if the medication is indicated. Before initiating any intervention, the nurse must determine if the intervention is still necessary. Before administering blood pressure medication, the blood pressure must be assessed. The client's reaction to the medication previously does not indicate if the medication is indicated at this time. The client's ability to verbalize the purpose of the medication is important to promote self-care, but it is not important for the client's safety at this time. The client's report of side effects would indicate an adverse reaction after the medication is administered, but it would not protect the client's safety before the medication is given.

The nurse has assisted the client to ambulate for the first time. After returning the client to bed, what is the nurse's priority intervention? a. Assess the client's response to the ambulation. b. Inform the client when ambulation is scheduled next. c. Discuss the client's feelings about the illness. d. Document the client's ambulation.

a. Assess the client's response to the ambulation. After a nurse has performed an intervention, the next step is to evaluate the effectiveness of the intervention. The nurse should assess the client's response to the ambulation. Informing the client when ambulation is scheduled next, discussing the client's feelings, and documenting the ambulation are important, but not until after the client has been reassessed.

Which nursing action can be categorized as a surveillance or monitoring intervention? a. Auscultating of bilateral lung sounds b. Providing hygiene c. Administering a paracetamol tablet d. Use of therapeutic communication skills

a. Auscultating of bilateral lung sounds Surveillance or monitoring nursing interventions include detecting changes from baseline data and recognizing abnormal responses. Nurses rely on the senses to detect changes: observing the appearance and characteristics of clients; hearing by auscultation, pitch, and tone; detecting odors and comparing them with past experience and knowledge of specific problems; and using touch to assess body temperature, skin condition, clamminess, or diaphoresis. Nurses use all of these surveillance or monitoring activities to determine the current status of clients and changes from previous states. Nurses often detect subtle changes in a client's condition and communicate them to the physician to minimize problems. Providing hygiene and administering a paracetamol tablet are examples of maintenance nursing interventions. Use of therapeutic communication skills is an example of a supportive nursing intervention.

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

a. Bed bath for the newly admitted client who has multiple skin lesions The safest delegation is to have the UAP bathe the client with skin lesions and report any abnormal findings to the nurse. Preparing insulin is outside of the UAP's scope of practice. The UAP may have the skills to insert an indwelling catheter and ambulate clients, but the clients involved each have qualifiers that complicate the tasks.

half of what the doctor ordered." How would the nurse most effectively meet this client's need? a. Collaborate with other disciplines to determine the best way to meet the client's medication requirements. b. Reinforce to the client and family the necessity of taking all medication as ordered to stabilize the client's condition. c. Inform the physician of the need to prescribe a less expensive medication for the client's condition. d. Instruct the client that some pharmaceutical companies have programs to help with medication expenses.

a. Collaborate with other disciplines to determine the best way to meet the client's medication requirements. In order to meet the client's needs, it is most important to involve other disciplines in the client's care to utilize all available resources. Reinforcing the importance of the medication does not solve the financial problem. It may be necessary for the physician to prescribe a less expensive medication, but other options should be considered to address the holistic needs of the client. Some pharmaceutical companies have programs to help with medication expenses, but the client will need information in order to apply for the programs.

A client in the last stages of pancreatic cancer tells the nurse, "I am tired of fighting. I am ready to die." What is the nurse's best action? a. Collaborate with other disciplines to plan end-of-life care for the client. b. Research other treatment options available for the client. c. Remind the client that positive thoughts are essential for recovery. d. Ask if the client would like to speak with a spiritual adviser.

a. Collaborate with other disciplines to plan end-of-life care for the client. The client has indicated an acceptance of the terminal condition. To respect the client's wishes, the nurse should involve other disciplines, such as hospice care, in planning for the client's needs. The client has not asked the nurse for other treatment options, so researching other options is not honoring the client's wishes. Reminding the client to think "positive thoughts" dismisses the seriousness of the client's concerns. Speaking with a spiritual adviser might be part of the collaborative care, but it would not address all the client's needs.

Discharge plans for a client with a mental health disorder include living with family members. The nurse learns that the family is no longer willing to allow the client to live with them. What is the nurse's most appropriate action? a. Collaborate with other disciplines to revise the discharge plans. b. Instruct the client to make alternate living arrangements. c. Communicate with the physician about additional orders. d. Inform the family that it is not possible to change the discharge plans.

a. Collaborate with other disciplines to revise the discharge plans. The discharge needs of this client are complicated, and the nurse will need the assistance of other disciplines to make a successful discharge plan. The client should have input into the future living arrangements, but the client does not have the resources to make the arrangements alone. The physician may be involved in the discharge plan, but additional orders are not necessary. It is not true (and would be inappropriate) to tell the family that discharge plans cannot be changed. If the family is unwilling to take the client, the placement will be unsuccessful.

The nurse is caring for a vegetarian who has iron deficiency anemia. The standardized nutritional plan for a client with anemia calls for the client to increase consumption of animal protein. How should the nurse plan to meet this client's nutritional needs? a. Collaborate with the nutritionist to modify the nutritional plan. b. Instruct the client that consumption of animal protein is necessary to cure the anemia. c. Meet with the client's family to emphasize the importance of nutritional modification. d. Arrange for animal protein to be disguised in the client's meal.

a. Collaborate with the nutritionist to modify the nutritional plan. A vegetarian does not consume animal proteins. Although animal proteins are an important source of iron, plant proteins are available. To honor the preferences of the client, the nurse would collaborate with the nutritionist to include these plant sources of protein in the client's diet (instead of the animal protein). It is not true that the client has to consume animal protein to cure the anemia. Meeting with the client's family would be inappropriate because this would violate the wishes of the client. Arranging for animal protein to be disguised in the client's meal would violate the client's trust and would also not be effective in the long term after the client has been discharged.

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. Ask the client if the client has any questions. d. Leave written information for the client to read later.

a. Delay the instruction until the visitors leave. The nurse must take into consideration the client's developmental level and willingness to participate in care in order to successfully implement the plan of care. The client is a teenager and socialization with a peer group is essential, so the nurse would most appropriately wait until the visitors leave. Telling the visitors to leave in 10 minutes might upset the client and hinder the education. Simply asking if the client has questions does not appropriately educate the client. Leaving written information does not ensure that the client will read or understand the information.

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. Encourage the client to provide as much self-care as possible. b. Perform all care activities for the client to facilitate rest. c. Teach the family to anticipate the client's needs to care for the client. d. Arrange with the nurse case manager for an early discharge.

a. Encourage the client to provide as much self-care as possible. The nurse must encourage the client to provide as much self-care as possible in order to achieve the highest level of independence. Performing all care activities for the client makes the client dependent on the nurse. If the family anticipates and meets all the client's needs, this also hinders the client's recovery. An early discharge is not indicated because the client must be sufficiently recovered.

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. Determine the frequency of pain medication. c. Medicate the client with the ordered pain medication. d. Instruct the client in nonpharmacologic pain management.

a. Go to the client and assess the client's pain. The nurse's first action should always be to determine the cause of the client's pain in order to determine the correct intervention. After determining the cause, the nurse can plan how to proceed. The other steps would be appropriate, but only after the assessment.

a. Psychosocial background The nurse is demonstrating an awareness of the client's psychosocial background, which includes consideration of the client's socioeconomic status. Research findings and current standards of care are examples of nursing variables. Developmental stage is a client variable that addresses the developmental needs of a client.

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. Reassess the client to determine the effectiveness of the 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. Perform additional nonpharmacological pain interventions.

a. Reassess the client to determine the effectiveness of the interventions. After implementing any interventions (such as pain medication or any nonpharmacological pain control method, such as splinting the incision), the nurse must always reassess the client to determine the effectiveness of the interventions. It is more likely that the pain medication is available on an as-needed basis rather than at regular intervals; in any case, informing the client of the availability of pain medication is of lower priority than reassessing the client to determine the effectiveness of the interventions performed. There is no need to inform the physician that the client has required pain medication; the physician anticipated the client needing pain medication, which is why the physician ordered the medication for the client to begin with. After evaluating the effectiveness of the implemented interventions, if the nurse finds that they have been ineffective, then the nurse would then revise the plan and include additional interventions, including, possibly, other nonpharmacological pain interventions.

A nurse in the intensive care unit (ICU) has been assigned to care for a client who was seriously injured during a gang rape. The nurse was raped 6 months ago and fears being too upset to care for the client properly. How should the nurse deal with the assignment? a. Recognize the nurse's own limitations and ask for another nurse to be assigned. b. Recognize that the nurse may be faced with this issue again and care for the client. c. Recognize the nurse's own limitations and ask another nurse to assist if the nurse becomes too emotional. d. Recognize the issue and care for the client to the best of the nurse's ability.

a. Recognize the nurse's own limitations and ask for another nurse to be assigned. The nurse should keep the client's best interests in mind. If the nurse feels that the nurse's emotional state would compromise the client's care, the best course would be for the nurse to request a different assignment. The other courses of action leave the possibility that the client's care could be compromised.

A nurse in the intensive care unit (ICU) has been assigned to care for a client who was seriously injured during a gang rape. The nurse was raped 6 months ago and fears being too upset to care for the client properly. How should the nurse deal with the assignment? a. Recognize the nurse's own limitations and ask for another nurse to be assigned. b. Recognize that the nurse may be faced with this issue again and care for the client. c. Recognize the nurse's own limitations and ask another nurse to assist if the nurse becomes too emotional. d. Recognize the issue and care for the client to the best of the nurse's ability.

The nurse is preparing to give the client a bath early in the morning. The client states, "I prefer to take my bath at night. It helps me sleep." What is the nurse's most appropriate action? a. Reschedule the client's bath to the evening shift. b. Ask the client for permission to give the bath in the morning. c. Tell the client that the physician has ordered sleep medication if necessary. d. Determine whether the nurses have time to give the client's bath at night.

a. Reschedule the client's bath to the evening shift. The client's preferences are a primary consideration in scheduling interventions. The client's preference to have a bath at night requires a change in scheduling. Asking for permission to give the bath in the morning does not address the client's preference. The schedule of the nurses should not take priority over client needs. Informing the client about sleep medication does not address the client's preference.

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. Consult with the physical therapist to determine the client's ability. d. Instruct the client's family to assist the client to ambulate to the bathroom.

a. Revise the care plan to allow the client to ambulate to the bathroom independently. The intervention of assisting the client to the bathroom is no longer indicated, so the nurse would appropriately revise the care plan to discontinue that intervention. A consult with a physical therapist is not necessary to verify the nurse's independent assessment. If the client is safe to ambulate to the restroom independently, it is not necessary for the family to assist.

While observing a new nurse inserting an indwelling urinary catheter, the preceptor observes a break in sterile technique. What is the preceptor's first action? a. Tell the new nurse that a break in sterile technique has occurred and the procedure must be stopped. b. Allow the new nurse to continue with the insertion and discuss the error later away from the client. c. Report the new nurse's error to the nurse manager for corrective action. d. Assign the new nurse to view videos on sterile catheter insertion.

a. Tell the new nurse that a break in sterile technique has occurred and the procedure must be stopped. The most important priority is to ensure the client's safety. Because the new nurse has contaminated the sterile field, the risk of introducing infection is high. The procedure must be discontinued. Because the preceptor is working with the new nurse, it would not be necessary to report the new nurse's error to the nurse manager unless it became a pattern of behavior. Assigning the nurse to watch instructional videos might be appropriate, but after the client care issue is resolved.

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's respiratory rate decreases. b. The client states, "I can breathe easier now." c. The client's oxygen saturation level increases. d. The client is watching television. e. The client's family asks if the client is going to be okay.

a. The client's respiratory rate decreases. b. The client states, "I can breathe easier now." c. The client's oxygen saturation level increases. When reassessing the client after implementing interventions to increase oxygenation, the nurse would look for a decrease in respiratory rate to a more normal rate and an increase in the oxygen saturation level. The client's subjective statement of breathing easier would also indicate effectiveness. The client watching television and the client's family's statement do not indicate anything about oxygenation status.

A client who has been in a vegetative state for years is scheduled for an elective surgery. The nurse is questioning whether the procedure is necessary. What is the nurse's appropriate first action? a. The nurse should address the concern with the surgeon. b. The nurse should address the concern with the hospital attorney. c. The nurse should address the concern with the hospital ethics committee. d. The nurse should address the concern with the client's family.

a. The nurse should address the concern with the surgeon. The nurse should first address the concern with the surgeon who has scheduled the procedure. If the nurse still has concerns after the discussion with the surgeon, the other choices are possible courses of action.

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 should inform the charge nurse that the nurse does not have the experience to properly care for this client. The nurse should recognize that the nurse lacks the competence to safely care for a client with these complex needs and inform the charge nurse of the fact. This assignment would be an inappropriate delegation on the part of the charge nurse and could cause injury to the client. The other options do not take the safety of the client into consideration.

A nursing student received a report on his assigned clients for the clinical day. Which client should the student nurse plan to assess first?

an asthma client who reports shortness of breath with a respiratory rate of 26 bpm

assisting the client with personal hygiene needs and ambulation transporting the infant to the mother's room according to hospital policy

Which nursing action can be categorized as a surveillance or monitoring intervention?

auscultating of bilateral lung sounds Surveillance or monitoring nursing interventions includes detecting changes from baseline data and recognizing abnormal responses

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 client to verbalize the medication regimen and diet modifications required. c. Ask the nutritionist to give the client strict meal plans to follow. d. Refer the client to available community resources and support groups.

b. Ask the client to verbalize the medication regimen and diet modifications required. If the nurse suspects a client does not understand instructions, the first step is to assess the client's understanding. The most effective way to do that is to have the client repeat the client's understanding of the instructions. The other steps might be interventions that the nurse would institute after determining the client's needs.

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. Assisting the client with personal hygiene needs and ambulation c. Assisting and teaching the client to breastfeed the infant d. Providing routine discharge instructions related to infant care e. Transporting the infant to the mother's room according to hospital policy

b. Assisting the client with personal hygiene needs and ambulation e. Transporting the infant to the mother's room according to hospital policy It is essential when delegating duties that the registered nurse (RN) is aware the nurse's role and what duties can be delegated. The nurse also must be aware of the training and the competence of the UAP. The nurse could appropriately delegate assisting with personal hygiene needs, ambulation, and transporting the infant to the mother's room according to hospital policy. Assessment is the role of the RN and cannot be delegated. Teaching, including breastfeeding education and discharge instructions, is also the role of the RN and cannot be delegated.

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 the risks and benefits of a blood transfusion with the client. b. Discuss possible alternatives to a blood transfusion with the physician. c. Discuss the client's options with other church members. d. Discuss the client's refusal with hospital risk managers.

b. Discuss possible alternatives to a blood transfusion with the physician. As coordinator of the client's care, the nurse functions as an intermediary between the physician and the client. In order to honor the client's wishes, the nurse would most appropriately consult with the physician to meet the client's physical needs, as well as the client's spiritual needs. The risk and benefits of a blood transfusion are not the relevant issue with the client. Discussing the client's options with other church members would violate the client's privacy and would not meet the client's physical needs. It might be advisable to discuss the client's refusal of care with the hospital risk manager to protect the legal requirements of the institution, but it is not the priority.

A nurse is catheterizing a client. Which scenario demonstrates steps the nurse would take to ensure client respect and privacy? a. Verify the client's identifiable information, explain the procedure to the family, and pull the privacy curtain to allow the client to feel comfortable in having family close by. b. Explain the procedure to the client, close the door to the room, and cover all areas of the client, only exposing the area for catheterization. c. Ask family members to leave the room briefly, close the door, and ask the client if he or she would like a sheet to cover oneself. d. Bring in another nurse to provide support and prevent questionable behaviors, explain the procedure to the client, and close the door and privacy curtain prior to beginning the procedure.

b. Explain the procedure to the client, close the door to the room, and cover all areas of the client, only exposing the area for catheterization. It is important to think about the environment for each intervention. Pay special attention to respecting the client's privacy and dignity; for example, close the door to the room or pull the drapes between the beds. To demonstrate respect, the procedure should be explained to the client and all areas except the sterile area should be covered to protect modesty and privacy. Asking another nurse to assist is helpful, but not required and may make the client feel awkward. There is not need to discuss with the family, because the client does not have any cognitive issues.

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

b. Inform the client what to expect after the surgery. If the surgery is an emergency, the highest priority is to meet the client's immediate needs. The nurse should inform the client about what to expect after surgery. Discussing discharge plans, instructing in wound care, and teaching about dietary restrictions are important, but not necessary before the surgery.

Which nursing action would be most effective in helping a client learn self-care behaviors? a. Check with the client to ensure that personal self-care goals are being met. b. Model self-care behaviors for the client. c. Collect data on the number of self-care activities the client has performed that day. d. Ask client to discuss the client's goals for the day at the start of the shift.

b. Model self-care behaviors for the client. Modeling self-care behaviors is a nursing intervention and is the action most effective in helping the client learn the self-care behaviors. The other answer options refer to evaluation of the client's response to interventions related to learning self-care behaviors.

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. Registered nurse b. Nursing assistant c. A senior nursing student present for clinical d. Licensed practical nurse

b. Nursing assistant The nurse should avoid delegating the dressing change to the nursing assistant. The dressing change would be within the scope of practice of the registered nurse, licensed practical nurse, and the senior nursing student.

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. Registered nurse b. Nursing assistant who is a nursing student c. A senior nursing student present for clinical d. Licensed practical nurse

b. Nursing assistant who is a nursing student The nurse should avoid delegating this client to the nursing assistant who is a nursing student. Suctioning and the associated evaluation of the client would be within the scope of practice of the registered nurse, licensed practical nurse, and the senior nursing student present for clinical.

The emergency room (ER) has a strict protocol regarding intramuscular (IM) injection technique. A nurse working in the ER has learned of a new technique to decrease pain with IM injections from the nursing literature and would like to use it. What is the most appropriate way for the nurse to implement the technique? a. Begin using the technique to determine whether it is effective. b. Petition to change the protocol based on the new evidence. c. Ask the ER physician to order IM injections with the new technique. d. Research the protocols at other area emergency rooms.

b. Petition to change the protocol based on the new evidence. The nurse should petition to change the protocol on the basis of the new evidence. If the nurse believes that the change would be beneficial to clients, it is important to change the procedure for all clients. Therefore, having the ER physician write orders would not be the best choice because it would not affect all clients. Because the nurse must function under the protocols of the agency, it would be wrong to begin using the technique before the protocol is changed. Protocols at other area emergency rooms are not as authoritative as evidence from the nursing literature.

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. Reassess the appropriateness of the method of instruction. It is the nurse's responsibility to revise the plan of care if an intervention is not successful. The most appropriate action of the nurse would be to determine if the initial education was the most effective for this client. Simply teaching the content again without reassessing the client's needs would not necessarily be effective. A support group might be helpful, but not until the client's needs are evaluated. The case manager is not responsible for the client's learning.

An indwelling urinary catheter has been ordered for a client experiencing urinary retention after surgery. When the nurse enters the room to place the catheter, the client reports voiding in the bathroom. Which is the nurse's most appropriate action? a. Insert the urinary catheter as ordered to relieve the urinary retention. b. Reassess whether the client still needs the urinary catheter. c. Instruct the client that the catheter is essential to check for urinary retention. d. Inform the client that the catheter will no longer be necessary.

b. Reassess whether the client still needs the urinary catheter. Before any intervention is implemented, the nurse should assess whether the intervention is still indicated. In this case, the client's report of voiding makes it all the more essential that the nurse assess whether the client is still retaining urine before inserting the catheter. The nurse should not tell the client the catheter is necessary or unnecessary until after the nurse has completed the assessment and confirmed whether it is necessary.

The registered nurse (RN) is delegating the task of assisting a postoperative client to the bathroom to the unlicensed assistive personnel (UAP). The nurse witnessed the UAP correctly perform the task on previous occasions and knows the UAP is competent to perform the task. The nurse has communicated how to get the client out and back into bed and told the UAP not to allow the client to bear weight on the left leg. The nurse validated that the activity was completed and gave the UAP feedback. Which delegation guideline did the nurse omit? a. Right task b. Right circumstance c. Right person d. Right supervision

b. Right circumstance The nurse fails to follow the delegation guideline related to right circumstance. The RN did not assess the client's needs or identify the outcome to be achieved by the task that was delegated. The other guidelines were followed.

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. Medications used to treat diabetes mellitus b. Risk factors for and prevention of diabetes mellitus c. The severity of the client's disease d. The cellular metabolism of glucose

b. Risk factors for and prevention of diabetes mellitus An important nursing function is to enable clients to prevent illness. Because a member of the family has developed diabetes, the other family members are also at risk. The nurse would most appropriately educate the family about the risk factors for and prevention of diabetes mellitus. Knowledge of the medications used to treat diabetes is not necessary at this time and does not help meet the family's needs. The severity of the client's disease does not have an impact on the family's health. Knowledge of the cellular metabolism of glucose is not necessary for the family's health.

The nurse is caring for a postoperative client who is receiving morphine sulfate for pain management. The nurse obtains the following vital signs: heart rate, 74 beats/min; respiratory rate, 8 breaths/min; blood pressure, 114/68 mm Hg. After reviewing the nursing care plan and physician orders, the nurse administers naloxone. Which would allow the nurse to initiate this action? a. Algorithm b. Standing orders c. Protocol d. Order set

b. Standing orders Standing orders allow the nurse to initiate actions that ordinarily require the order of a physician, such as administering naloxone. An algorithm is a binary decision tree that guides stepwise assessment and intervention for a high-risk subgroup of clients. A protocol is a written plan that details nursing activities to be executed in specific situations. An order set is a preprinted set of provider orders that expedite the provider order process.

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. "My daughter has been staying with me the past few weeks." b. "I asked my neighbors to help me with my yard work." c. "My wife's been gone for about 7 months now." d. "I sort my medication into an organizer every week."

c. "My wife's been gone for about 7 months now." The client's loss may be affecting how well the client is able to provide self-care. The client may be depressed and questioning the benefits of the health care regimen, or the client may have depended on the wife to help with health care and no longer has the ability to take care of himself. Assessment of the client allows the nurse to alter the plan of care to meet the client's needs. The statements concerning having a family member staying with the client, having help with the yard work, and sorting medications into an organizer all indicate factors that would improve the client's ability to provide self-care, not decrease it.

A client requires a change and reapplication of a colostomy bag. The nurse has never changed an ostomy bag before. What is the nurse's best course of action? a. Ask the client how the bag is changed. b. Read the policy and procedure manual. c. Ask a skilled nurse to assist with the procedure. d. Determine the necessity of the bag change.

c. Ask a skilled nurse to assist with the procedure. Professional nurses should only undertake tasks that they have been properly trained to perform. Because the nurse has no experience in changing an ostomy bag, it would be most appropriate to have the assistance of an experienced nurse. It would be inappropriate to ask the client how the bag is changed. The client is relying on the nurse to have the necessary technical knowledge. Reading the policy and procedure manual alone would not ensure the successful completion of the procedure. The necessity of the ostomy bag change has already been established.

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. Ask the surgeon to wait until the client has had a chance to talk to the spouse. It is important to consider the client's wishes, so the nurse should advocate for the client and ask the surgeon to wait until the client has talked to the spouse. Telling the client that the client is responsible for the client's own health care decisions does not respect the client's desire to consult the spouse. The client has not expressed being fearful of the spouse. Informing the surgeon that the nurse will not sign the consent form will not satisfy the client's request.

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. Instruct the client about the need to keep the walkway to the bathroom clear. c. Assist the client to identify strategies to promote safety in the home. d. Assign a home health aide to perform housekeeping duties.

c. Assist the client to identify strategies to promote safety in the home. The best way to address safety in the home is to discuss the issue with the client. Because the client has a visual deficit, clutter in the pathway to the bathroom may not be the only hazardous condition in the home. Helping the client identify safety strategies will help the client be more independent and will promote safety in the long run. Removing the cluttered objects would be important for the client's immediate safety, but would not help keep the client safe in the long run. Instructing the client to keep the walkway clear without identifying ways to do it would not keep the client safe. A home health aide could be part of the overall strategy to help protect the client, but the aide will not be present all the time to protect the client.

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

c. Communicate with the physician for additional orders. If the nurse's interventions have been ineffective, the physician must be notified of the client's deteriorating status. The physician can direct other medical interventions. Documenting the interventions does not take priority over the client's physiologic needs. Allowing another 30 minutes to elapse before taking action will only cause further deterioration in the client's status. The nurse should know the client's code status when taking over the client's care.

The nurse is caring for a client who is recovering from a cerebrovascular accident. When reviewing the client's orders, the nurse notes that one of the physicians wrote orders to ambulate the client, whereas another physician ordered strict bed rest for the client. How would the nurse most appropriately remedy this conflict? a. Assess the client to determine whether the client is capable of ambulation. b. Instruct the client to ask the physicians for clarifications of instructions. c. Communicate with the physicians to coordinate their orders. d. Collaborate with the physical therapist to determine the client's ability.

c. Communicate with the physicians to coordinate their orders. As coordinator of care, the nurse is responsible for ensuring the continuity of the treatment plan. If conflicts occur in the treatment plan, the nurse should first consult with the physicians who have written the conflicting orders. The nurse may assess the client to determine whether the client is capable of ambulation, but this does not resolve the conflict or determine whether ambulation is in the client's best interest. It is not the client's responsibility to clarify nursing orders. Collaboration with the physical therapist could become part of the plan later, but the physicians' orders have to be clarified first.

c. Coordinating Coordination involves acting as a client advocate, making referrals for follow-up care, collaborating with other health care team members, and ensuring that the client's schedule is therapeutic. This is not a surveillance or technical type of intervention. The nurse is being supportive of the client, but advocacy is more closely associated with coordinating types of interventions.

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. Continue the education and remind the client that it is essential to learn self-care. b. Medicate the client for anxiety and continue the education later. c. Discontinue the education and attempt at another time. d. Discontinue the education and ask the client for permission to teach a family member.

c. Discontinue the education and attempt at another time. The nurse should always perform client education when the client is receptive of the education. The client verbalizes not being ready to learn, so education should be discontinued and continued at another time. Asking for permission to teach a family member does not encourage the client to learn self-care and acquire independence. The client does not need medication for anxiety at this time. This is a normal reaction. It would not be productive to continue the education because the client is not ready to learn.

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. Review with the client the risks and benefits of surgery. b. Ask the client to discuss the decision with family members. c. Discuss with the client the reasons for declining surgery. d. Notify the physician of the client's refusal.

c. Discuss with the client the reasons for declining surgery. The nurse needs further information before deciding what interventions are necessary, so the most appropriate action is to determine the client's reasons for refusal. Until the information is collected, the nurse cannot decide whether reviewing the risks and benefits of surgery would be effective. It is also premature to ask the client to discuss the decision with family members. It is not appropriate to notify the physician until the assessment is complete.

The nurse in a burn intensive care unit (BICU) is caring for a 3-year-old child who was burned with scalding hot water. The client has burns covering 75% of the body. The client's condition is critical but stable. At 1000, the nurse reassesses the client and finds that the client is agitated and pulling at the endotracheal tube. Which is the nurse's priority intervention for this client at this time? a. Providing medication for agitation b. Repositioning to prevent pressure injuries c. Ensuring that the endotracheal tube is secure d. Changing the dressing to prevent infection

c. Ensuring that the endotracheal tube is secure The ABCs (airway, breathing, and circulation) are always top priority in client care. In this example, ensuring that the client maintains a patent airway will always be top priority. Each of these nursing tasks is important and will need to be accomplished at some point during client care.

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

c. It enables the nurse to revise the care plan appropriately. Continuous data collection ensures that the nurse has the most current client data to evaluate, which allows for updating the care plan as needed. A complete assessment is performed on admission, but the client's condition is always changing. The purpose of continued data collection is to provide good client care; it does not relate directly to efficiency of nursing care. While continuous data collection meets standards of care, it is not the primary reason for ongoing assessments.

A nurse is administering metformin to a client who has a new onset of diabetes mellitus type 2. Which step should the nurse consider a priority on the nursing care plan? a. Restrict intake of foods and fluids. b. Monitor for noncompliance. c. Monitor for lactic acidosis d. Administer B12 injections

c. Monitor for lactic acidosis In this scenario, the nurse is administering a medication. Because an action is being carried out, this is the implementation step of the nursing process. Following the administration of medication, the nurse should monitor the client for lactic acidosis as well as side effects of the medication. Restricting the client's food and fluids while the client is on metformin is only suggested when the client is preparing for a procedure requiring the client to be NPO. B12 injections may be indicated in the future as treatment has been established. Likewise, it is too early in the treatment plan to monitor for noncompliance.

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. Inform the client that it is not necessary to wash hands before vital signs. b. Reassure the client that the nurse knows when to perform hand hygiene. c. Praise the client for taking an active role in the client's care. d. Tell the client that gloves are required for this procedure.

c. Praise the client for taking an active role in the client's care. Clients should be empowered to take responsibility for self-care. All clients should be taught that they have the power to question any part of their care. The nurse would appropriately praise the client. It is necessary to wash hands before taking vital signs; gloves are not required for the procedure. Telling the client that the nurse knows when to perform hand hygiene is disrespectful of the client's concern.

Which task would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? a. Secure the client's jewelry before surgery. b. Reassess the client's sacrum for redness when doing a bed bath. c. Provide the client with assistance in transferring to the bedside commode. d. Retrieve a unit of blood from the blood bank.

c. Provide the client with assistance in transferring to the bedside commode. Assisting with toileting is one of the tasks the state board of nursing permits UAPs to perform. UAPs commonly performed this task in health facilities. Each of the other responses demands a level of responsibility that the nurse cannot legally delegate to a UAP.

The nurse is planning instruction on wound care to an adult client. What variables would cause the nurse to alter the education plan? Select all that apply. a. The client is male. b. The client is married. c. The client is blind. d. The client is an architect. e. The client denies the need for education.

c. The client is blind. e. The client denies the need for education. The client's blindness will require the nurse to alter the education plan to fit the client's needs. The education might also require teaching another person to perform the wound care. If the client denies the need for education, attempting to teach the client at this time will be ineffective. The nurse will need to determine why the client denies the need for teaching and address that issue first. The facts that the client is male, married, and an architect do not have any bearing on the instruction.

The registered nurse is working with an unlicensed assistive personnel. Which client should the nurse not delegate to the unlicensed assistive personnel? a. The client who needs vital signs taken following infusion of packed red blood cells. b. The client who requires assistance dressing in preparation for discharge. c. The client with continuous pulse oximetry who requires pharyngeal suctioning. d. The client who is pleasantly confused and requires assistance to the bathroom.

c. The client with continuous pulse oximetry who requires pharyngeal suctioning. The nurse needs to perform the pharyngeal suctioning of the client with continuous pulse oximetry. This client requires the nurse to evaluate the client's response in pulse oximetry to the suctioning. The nurse can delegate the other clients to the unlicensed assistive personnel.

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. Educational b. Psychomotor c. Maintenance d. Surveillance

d. Surveillance Surveillance interventions include detecting changes from baseline data and recognizing abnormal response. Nurses rely on the senses to detect changes, such as observing the appearance and characteristics of clients and hearing by auscultation, pitch, and tone. Nurses use these surveillance activities to determine the current status of clients and changes from previous states. Educational interventions require instruction, demonstration, and return demonstration of knowledge or a skill set. Psychomotor interventions involve the nurse physically working with the client. Maintenance interventions involve the nurse assisting the client with performing routine activities of daily living.

Priority setting is based on the information obtained during reassessment and is used to rank nursing diagnoses. Each factor contributes to priority setting except which? - The client's condition - Time and resources - Feedback from the family - Finances of the client

finances of the client Explanation: The client's condition, time and resources, and feedback or input from the family are all of great value when the nurse is prioritizing the client's nursing diagnoses. The client's finances, however, should not influence the nurse's priority setting. The nursing code of ethics states that clients should receive the same treatment regardless of their ability to pay.

The primary purpose of nursing implementation is to:

help the client achieve optimal levels of health.

outcome evaluation

The registered nurse (RN) is delegating the task of assisting a post-operative client to the bathroom to the unlicensed assistive personnel (UAP). The nurse witnessed the UAP correctly perform the task on previous occasions, and knows the UAP is competent to perform the task. The nurse has communicated how to get the client out and back into bed, and told the UAP not to allow the client to bear weight on the left leg. The nurse validated that the activity was completed and gave the UAP feedback. Which delegation guideline was omitted by the nurse?

right circumstance

risk factors and prevention of diabetes mellitus

A nurse follows set guidelines for administering pain medication to clients in a critical care unit. This nurse's authority to initiate actions that normally require the order or supervision of a physician is termed:

standing orders Standing orders empower the nurse to initiate actions that ordinarily require the order or supervision of a physician, such as pain medication administration based on specific criteria. Protocols are written plans that detail the nursing activities to be executed in specific situations; these include routine nursing care and standing orders. Nursing interventions refer to care administered by the nurse and can be dependent or independent in nature. Collaborative orders may include suggested care strategies from other health care personnel such as the physical therapist.

standing orders. Explanation: Standing orders empower the nurse to initiate actions that ordinarily require the order or supervision of a physician, such as pain medication administration based on specific criteria. Protocols are written plans that detail the nursing activities to be executed in specific situations; these include routine nursing care and standing orders. Nursing interventions refer to care administered by the nurse and can be dependent or independent in nature. Collaborative orders may include suggested care strategies from other health care personnel such as the physical therapist.

transporting the infant to the mother's room according to hospital policy assisting the client with personal hygiene needs and ambulation

indirect care

treatment performed away from the patient but on behalf of a patient or group of patients

Which examples of nursing actions involve direct care of the client? Select all that apply.

• A nurse counsels a young family who is interested in natural family planning. • A nurse massages the back of a client while performing a skin assessment. • A nurse helps a client in hospice fill out a living will form.

Which is a responsibility of the nurse in the nurse-health care team relationship? Select all that apply.

• Serve as a liaison between the client and family and the health care team. • Coordinate the inputs of the multidisciplinary team into a comprehensive plan of care.

The nurse is planning instruction on wound care to an adult client. What variables would cause the nurse to alter the education plan? Select all that apply.

• The client is blind. • The client denies the need for education.

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) Supportive B) Surveillance C) Collaborative D) Maintenance

B) Surveillance

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?

Ask the client to verbalize the medication regimen and diet modifications required.

A client cannot afford the treatment prescribed. Who would be the most appropriate professional for the nurse to involve with the client's care?

Nurse case manager

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

Nurse case manager Explanation: The nurse case manager is the expert on resources available for the client's care. The nurse manager is responsible for the operation of the nursing unit. The physician is concerned with the client's medical needs. The insurance company is a possible resource, if the client has insurance coverage.

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?

Nursing assistant

A busy nurse is working with an unlicensed assistive personnel (UAP). What tasks can the nurse appropriately delegate to the UAP? Mark all that apply.

Record the client's intake and output. Assist the client to the bedside commode.

The client reports right knee pain of 6/10 on the pain scale and requests for medication. The nurse assesses and flushes the IV site. Which type of intervention skill is the nurse using?

Technical skill

The nurse is attending a conference on evidence-based practice. Which statement by the nurse indicates further education is needed? a. "I must conduct research to validate the usefulness of my nursing interventions." b. "I can learn about evidence-based practice by reading professional nursing journals." c. "Nursing interventions should be supported by a sound scientific rationale." d. "The Agency for Healthcare Research and Quality is a resource for evidence-based practice."

a. "I must conduct research to validate the usefulness of my nursing interventions." Nursing interventions should be supported by a sound scientific rationale; however, nurses do not need to personally conduct research to establish the rationale for nursing interventions. Nurses can learn about evidence-based practice by reading professional nursing journals, attending nursing workshops, and consulting evidence-based practice resources, such as the Agency for Healthcare Research and Quality.

The nurse is attending a conference on evidence-based practice. Which statement by the nurse indicates further education is needed?

"I must conduct research to validate the usefulness of my nursing interventions."

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) Encourage the client to provide as much self-care as possible. B) Perform all care activities for the client to facilitate rest. C) Teach the family to anticipate the client's needs to care for the client. D) Arrange with the nurse case manager for an early discharge.

A) Encourage the client to provide as much self-care as possible.

Priority setting is based on the information obtained during reassessment and is used to rank nursing diagnoses. Each factor contributes to priority setting except which? A) Finances of the client B) The client's condition C) Time and resources D) Feedback from the family

A) Finances of the client

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) Determine the frequency of pain medication. C) Medicate the client with the ordered pain medication. D) Instruct the client in nonpharmacologic pain management.

A) Go to the client and assess the client's pain.

A client requires a change and reapplication of a colostomy bag. The nurse has never changed an ostomy bag before. What is the nurse's best course of action?

Ask a skilled nurse to assist with the procedure. Professional nurses should only undertake tasks that they have been properly trained to perform. Since the nurse has no experience in changing an ostomy bag, it would be most appropriate to have the assistance of an experienced nurse Reading the policy and procedure manual alone would not ensure the successful completion of the procedure

The nursing is caring for several clients. Which intervention can the nurse direct the unlicensed assistive personnel (UAP) to perform? A) Take the vital signs of the client who just returned from surgery. B) Feed a client who is eating for the first time following an ischemic stroke. C) Bathe a client with stable angina who has a continuous IV infusing. D) Assist the client who is ambulating the first time since hip replacement surgery.

C) Bathe a client with stable angina who has a continuous IV infusing.

The nurse is caring for a client who is recovering from a cerebrovascular accident. When reviewing the client's orders, the nurse notes that one of the physicians wrote orders to ambulate the client, whereas another physician ordered strict bed rest for the client. How would the nurse mostappropriately remedy this conflict? A) Assess the client to determine whether the client is capable of ambulation. B) Instruct the client to ask the physicians for clarifications of instructions. C) Communicate with the physicians to coordinate their orders. D) Collaborate with the physical therapist to determine the client's ability.

C) Communicate with the physicians to coordinate their orders.

C) Coordinating

Discontinue the education and attempt at another time.

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? - Medicate the client for anxiety and continue the education later. - Continue the education and remind the client that it is essential to learn self-care. - Discontinue the education and ask the client for permission to teach a family member. - Discontinue the education and attempt at another time.

Discontinue the education and attempt at another time. Explanation: The nurse should always perform client education when the client is receptive of the education. The client verbalizes not being ready to learn, so education should be discontinued and continued at another time. Asking for permission to teach a family member does not encourage the client to learn self-care and acquire independence. The client does not need medication for anxiety at this time. This is a normal reaction. It would not be productive to continue the education because the client is not ready to learn.

Finances of the client The nursing code of ethics states that clients receive the same treatment regardless of their ability to pay.

What assessment data would indicate to the nurse at the conclusion of an education session that the client education was effective? Mark all that apply.

• The client verbalizes understanding of the instructions. • The client is able to answer the nurse's questions. • The client discusses the specifics of what was taught during the session.

• The client's respiratory rate decreases. • The client states, "I can breathe easier now." • The client's oxygen saturation level increases.

After instituting interventions to increase oxygenation, the client shows no signs of improvement. What is the nurse's priority action?

Communicate with the physician for additional orders

In order to successfully implement the plan of care, what parties are essential for the nurse to include?

Client, family, and physician

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. An older adult with pneumonia who is being discharged to the son's home tomorrow c. A middle-aged client who had abdominal surgery 3 days ago and is ambulating in the hall d. An adult client who is being treated for kidney stones

a. A client with a high fever receiving intravenous fluids, antibiotics, and oxygen For delegation, the circumstances must be right. The health condition of the client must be stable. The client with a high fever receiving intravenous fluids, antibiotics, and oxygen is the least stable of the clients listed and should be assessed by the nurse. Delegation of taking vital signs would be appropriate for all of the other client's described.

Priority setting is based on the information obtained during reassessment and is used to rank nursing diagnoses. Each factor contributes to priority setting except which? a. Finances of the client b. The client's condition c. Time and resources d. Feedback from the family

a. Finances of the client The client's condition, time and resources, and feedback or input from the family are all of great value when the nurse is prioritizing the client's nursing diagnoses. The client's finances, however, should not influence the nurse's priority setting. The nursing code of ethics states that clients should receive the same treatment regardless of their ability to pay.

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 has a 12-year-old sister who has been treated for a seizure disorder for 3 years. b. The client expresses a desire to learn how to manage the medication regime. c. The parents verbalize acceptance of the need to closely monitor their child's condition. d. The parents have comprehensive insurance coverage for their family's medical care.

a. The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years. If the family has experience caring for a child with a seizure disorder, the family would already have some basic knowledge, so the nurse would address the education differently. The client expressing a desire to learn indicates receptiveness to the education. The parents' acceptance of their child's condition indicates that they are ready to begin dealing with the child's condition. The fact that the child has comprehensive insurance coverage is a strength that will make options available to the family, but will not necessarily change the nurse's educational plan.

A client with diabetes who has been closely following the prescribed plan of care for over a year is being seen at an outpatient facility. The client has not brought a log of daily glucose checks and tells the nurse, "I haven't been doing them regularly." What is the nurse's most therapeutic statement to the client? a. "It is extremely important to your health to strictly follow your plan of care." b. "It seems like you are having difficulty with your care regimen." c. "Should I arrange for a home health nurse to coordinate your care?" d. "Should I instruct your family to do the glucose checks for you?"

b. "It seems like you are having difficulty with your care regimen." The nurse's open-ended statement acknowledging that the client is having difficulty with the care regimen encourages the client to discuss what has occurred that has caused the client to not manage the diabetes as was previously done. The statement reminding the client that health care is important will discourage the client to freely discuss any problems. A home health nurse or instructions given to the family may be indicated, but not until the client has verbalized the reasons why the care regimen has not been followed.

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. Supportive b. Surveillance c. Collaborative d. Maintenance

b. Surveillance Surveillance nursing interventions include detecting changes from baseline data and recognizing abnormal responses. Nurses rely on the senses to detect changes, such as observing the appearance and characteristics of clients and hearing by auscultation, pitch, and tone. Nurses use these surveillance activities to determine the current status of clients and changes from previous states. Maintenance nursing interventions involve the nurse assisting the client with performing routine activities of daily living. Supportive nursing measures involve providing basic comfort and emotional care to the client. Collaborative nursing interventions involve cooridination and communication with health care professionals in other fields to meet the client's needs.

The client has a diagnosis of Risk for Injury related to falls. How would the nurse know if the intervention was successful? a. The client calls for assistance to get out of bed. b. The client is free of falls. c. The client is taught safety precautions. d. The client verbalizes risks for injury.

b. The client is free of falls. Interventions for risk diagnoses are directed at prevention. The most appropriate way to evaluate the success of the interventions is to determine if the risk was prevented. The best evaluation criteria would be if the client remained free of falls. The client calling for assistance might prevent a fall, but does not signify that a fall will not occur. Teaching clients safety precautions and having the client verbalize risk for injuries is important but does not necessarily mean that an injury is prevented.

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. "It is a habit that nurses develop in school." b. "It is a hospital policy to reduce the potential for errors." c. "We ask your name to ensure that we are treating the right client." d. "We ask your name to show that we respect your rights."

c. "We ask your name to ensure that we are treating the right client." The primary reason for asking the client to state the client's name is to ensure that the nurse is dealing with the correct client. Asking the client to state the client's name is a habit that should be developed in nursing school, but that is not the reason nurses ask clients for their names. It is not just a hospital-specific policy to ask the client for the client's name, but it is a step that is used in all client care situations. Respecting clients' rights is important but that is not why nurses ask for their names.

The client tells the nurse, "I think the nurse last night may have given me the wrong medication, but I was afraid to say anything." What is the nurse's most appropriate response? a. "I will report your concerns to the nurse manager." b. "I will discuss your concerns with the night nurse." c. "You should always speak up if you have any questions about your care." d. "You always have the right to refuse any medication or treatment."

c. "You should always speak up if you have any questions about your care." The priority is to empower the client into taking an active role in the client's care, so the nurse should tell the client to feel free to ask questions. The client does have the right to refuse, but this does not address the issue. Speaking to the nurse manager or the night nurse does not help the client deal with a similar situation in the future.

The primary purpose of nursing implementation is to: a. improve the client's postoperative status. b. identify a need for collaborative consults. c. help the client achieve optimal levels of health. d. implement the critical pathway for the client.

c. help the client achieve optimal levels of health. The purpose of the nursing implementation phase is to help the client achieve an optimal level of health. Improving the client's postoperative status and implementing the critical pathway for the client are too narrow to represent the purpose of the implementation phase, although they are purposes of specific interventions that would be implemented during this phase. Identifying the need for collaborative consults is an action the nurse would perform in the planning phase of the nursing process.

d. standing orders. Standing orders empower the nurse to initiate actions that ordinarily require the order or supervision of a physician, such as pain medication administration based on specific criteria. Protocols are written plans that detail the nursing activities to be executed in specific situations; these include routine nursing care and standing orders. Nursing interventions refer to care administered by the nurse and can be dependent or independent in nature. Collaborative orders may include suggested care strategies from other health care personnel such as the physical therapist.

finances of the client

The primary purpose of nursing implementation is to: - identify a need for collaborative consults. - help the client achieve optimal levels of health. - improve the client's postoperative status. - implement the critical pathway for the client.

help the client achieve optimal levels of health. Explanation: The purpose of the nursing implementation phase is to help the client achieve an optimal level of health. Improving the client's postoperative status and implementing the critical pathway for the client are too narrow to represent the prupose of the implementation phase, although they are purposes of specific interventions that would be implemented druing this phase. Identifying the need for collaborative consults is an action the nurse would perform in the planning phase of the nursing process.

Chapter 17: Implementing

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