Chapter 17: Implementing PrepU
Which statement by a nurse case manager regarding this nurse's role in client care is most accurate? -"I provide indirect care to my clients by coordinating their treatment with other disciplines." -"Moving away from client care is a necessary step to advancing my career." -"I provide a critical service that is necessary for financial reimbursement." -"Even though I do not provide care to clients, my work is very important."
"I provide indirect care to my clients by coordinating their treatment with other disciplines." 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.
A nurse is developing a plan of care for a client and determines appropriate outcomes and interventions for this client. Which variable would be most appropriate for the nurse to address to ensure that the care plan meets the client's needs? Select all that apply. -Client's cultural background -Client's gender -Client's socioeconomic status -Client's developmental stage -Client's ability to participate
-Client's ability to participate -Client's developmental stage -Client's cultural background -Client's socioeconomic status Ideally, the client is primary in determining how nursing interventions are implemented. Successful nurses modify their nursing actions according to the client's changing ability, willingness to participate in the care plan, previous responses to nursing interventions, and progress toward achieving goals or outcomes. Other important variables are the client's developmental stage, psychosocial background (including socioeconomic status), and culture. Gender is not considered a variable that would affect the care plan.
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's respiratory rate decreases. -The client is watching television. -The client's family asks if the client is going to be okay. -The client states, "I can breathe easier now."
-The client's respiratory rate decreases. -The client states, "I can breathe easier now." -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 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 client with a high fever receiving intravenous fluids, antibiotics, and oxygen -An adult client who is being treated for kidney stones -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 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.
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? -Discuss the client's feelings about the illness. -Document the client's ambulation. -Inform the client when ambulation is scheduled next. -Assess the client's response to the ambulation.
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.
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? -Inform the client when ambulation is scheduled next. -Assess the client's response to the ambulation. -Discuss the client's feelings about the illness. -Document the client's ambulation.
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 is the priority question for the nurse to consider before implementing a new intervention? -What equipment do I need? -How much experience do I have with this treatment? -Does this treatment make sense for this client? -Will I need someone to assist me?
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.
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? -Changing the dressing to prevent infection -Providing medication for agitation -Ensuring that the endotracheal tube is secure -Repositioning to prevent pressure injuries
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.
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? -Ask the client's family to assist the client in following the plan of care. -Make changes in the plan of care based upon assessment data. -Discuss the desired outcomes with the client and the importance of the outcomes. -Provide information to the client on the benefits of complying with the plan of care.
Make changes in the plan of care based upon assessment data. A plan of care that is inappropriate for the client requires a change in the plan of care, not a change in the client. In situations when the plan of care is appropriate, the nurse must evaluate factors that contribute to the client's failure to comply. Such factors include lack of family support, lack of understanding of the benefits of compliance, low value attached to the outcomes and related interventions, and adverse or emotional effects of treatment.
Which task would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? -Provide the client with assistance in transferring to the bedside commode. -Assess an IV site for possible infiltration -Retrieve a unit of blood from the blood bank. -Reassess the client's sacrum for redness when doing a bed bath.
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.
A client is admitted to the mental health center after attempting suicide. Which client concern is the priority for the nurse to manage? -Lack of support -Feelings of not belonging -Low self-esteem -Risk of self-harm
Risk of self-harm Safety and security are the priority for the client, so the risk of self-harm is what the nurse must address first. Lack of support, low self-esteem, and feelings of not belonging, although still important to address, are not as critical as safety and security.
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 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 parents have comprehensive insurance coverage for their family's medical care.
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.
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 tells the nurse that the client's spouse will handle the care. -The client discusses the specifics of what was taught during the session. -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 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.
Which nursing intervention is most likely to be allowed within the parameters of a protocol or standing order? -Administering a beta-adrenergic blocker to a new client whose blood pressure is high on admission assessment -Administering a glycerin suppository to a constipated client who has not responded to oral stool softeners -Changing a client's intravenous (IV) fluid from normal saline to 5% dextrose -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 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.
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. -Instruct the client to ask the physicians for clarifications of instructions. -Communicate with the physicians to coordinate their orders.
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.
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. -Ask the client if the client has any questions. -Delay the instruction until the visitors leave. -Leave written information for the client to read later.
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.
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. -Discuss the risks and benefits of a blood transfusion with the client. -Discuss the client's options with other church members. -Discuss the client's refusal with hospital risk managers.
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 caring for a postoperative client who reports a pain level of 6 on a scale from 1 to 10. After administering the prescribed pain medication, which intervention should the nurse include in the nursing care plan to monitor and evaluate pain? -Implement the ABC guide of pain management. -Review client goals for comfort. -Ambulate the client after administration of pain medication. -Assess nonpharmacologic modalities used to reduce pain.
Implement the ABC guide of pain management. Because administering a pain medication is implementing the plan of care, the next step would be to monitor and evaluate the client's pain level. By using the ABC guide to pain management in reassessing the client's pain, the nurse knows whether the current plan of care is safe and effective for the client, or if changes need to be made to meet the client's needs. Stating the use of pharmacologic and nonpharmacologic pain management modalities and ambulation and reviewing goals for comfort are all interventions to reduce pain, not methods for monitoring pain or evaluating the current plan.
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? -Licensed practical nurse -A senior nursing student present for clinical -Nursing assistant -Registered nurse
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 senior nursing student present for clinical -Licensed practical nurse -Registered nurse -Nursing assistant who is a nursing student
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.
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? -Maintenance -Educational -Surveillance -Psychomotor
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.
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. -The nurse encourages clients to advocate for themselves instead of choosing a trusted family member or friend. -The nurse assures the client who questions a medication that it is the right medication prescribed for him or her and administers the medicine. -The nurse explains each procedure twice to prevent client questions from wasting time.
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.
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 best response? -Work with the evening shift to possibly reschedule. -Inform the client the evening shift will not have time to give baths. -Tell the client that the health care provider has prescribed sleep medication if necessary. -Ask the client for permission to give the bath in the morning.
Work with the evening shift to possibly reschedule. 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 and the nurse should discuss the issue with the evening shift to determine if rescheduling is possible. 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 desires. Informing the client about sleep medication does not address the client's preference. To just brush off the client's desires is not showing holistic nursing care.
