implementation prepu
A nursing student received a report on his assigned clients for the clinical day. Which client should the student nurse plan to assess first? a client who has had an appendectomy and has a temperature of 39.1 degrees C a newly diagnosed client with diabetes who is crying and states "I do not understand how to give my insulin." an asthma client who reports shortness of breath with a respiratory rate of 26 bpm a client who has had a hysterectomy and reports bleeding from the surgical site
an asthma client who reports shortness of breath with a respiratory rate of 26 bpm According to the ABC priority framework, the client who should be assessed first is the asthma client with shortness of breath and a respiratory rate of 26 bpm. The appendectomy client with an elevated temperature should be assessed for suspected infection. However, this is not the priority action. The diabetic client should receive education regarding administration of insulin but this is not a priority. The hysterectomy client should be assessed for possible hemorrhage. However, according to the ABC priority framework, this is not the priority.
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 work tomorrow because short-staffing is dangerous for the clients." "I will work tomorrow because the other nurses need my help." "I will not work tomorrow because I would be a danger to my clients." "I will not work tomorrow because I want to have a day off."
"I will not work tomorrow because I would be a danger to my clients." The nurse cannot care for client without first ensuring self-care. The nurse is tired and most appropriately is declining to work because the nurse will not be able to function at full capacity. Simply stating that the nurse wants a day off does not fully address the situation. The option of working tomorrow is not appropriate because the nurse needs to rest after working a night shift.
The nurse receives an order for 100mg of morphine sulfate IM to a postoperative client and knows that the usual dose is 10mg. Which question is most appropriate for the nurse to ask the provider? "Is the ordered dose of 100mg correct?" "Should the client receive the medication intravenously instead of IM? "Should I withhold the dose because the client has a blood pressure of 112/74?" "What time should the initial dose be given?"
"Is the ordered dose of 100mg correct?" To ensure the safety of the client, it is the nurse's responsibility to clarify any questionable orders. The nurse must ask the provider about the questionable dose of 100mg of morphine sulfate, knowing that it is around 10 times the dose normally prescribed. The route of administration and time of administration are not the priority issue that should be questioned with the provider. A blood pressure of 112/74 is not an indication to withhold the dose and does not reflect the nurse's concern about the high dose.
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." "I am taking a cooking class at the community college to learn new healthy cooking techniques." "We moved to a new neighborhood that has several walking trails, but they are all uphill and really difficult." "My son gave me a blood pressure machine to monitor my blood pressure at home, and I use it every day."
"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.
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." "I am taking a cooking class at the community college to learn new healthy cooking techniques." "We moved to a new neighborhood that has several walking trails, but they are all uphill and really difficult." "My son gave me a blood pressure machine to monitor my blood pressure at home, and I use it every day."
"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.
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 habit that nurses develop in school." "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."
"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.
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 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.
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? 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.
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.
The nurse is caring for a client admitted to the hospital for renal calculi. What is the action to take first? Force fluids by mouth. Diet as tolerated. Strain urine after each void. Assess for bladder distention.
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.
The nurse is caring for a client admitted to the hospital for renal calculi. What is the action to take first? Force fluids by mouth. Diet as tolerated. Strain urine after each void. Assess for bladder distention.
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.
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. Consult with the physician for additional pain medication. Discuss the frequency of pain medication administration with the client. Assist the client to reposition and splint the incision.
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? Assess the client's blood pressure to determine if the medication is indicated. Determine the client's reaction to the medication in the past. Ask the client to verbalize the purpose of the medication. Tell the client to report any side effects experienced.
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? Assess the client's response to the ambulation. Inform the client when ambulation is scheduled next. 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 nursing action can be categorized as a surveillance or monitoring intervention? Auscultating of bilateral lung sounds Providing hygiene Administering a paracetamol tablet Use of therapeutic communication skills
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)? Bed bath for the newly admitted client who has multiple skin lesions Preparation of insulin for the diabetic client with an elevated blood glucose level Ambulation of the client with a history of falls for the first time after surgery Insertion of a urinary catheter in a client with benign prostatic hypertrophy
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.
Which parties are essential for the nurse to include in the implementation of a client's plan of care? Client, family, and physician Client, physician, and hospital director Client, physical therapist, and nursing staff Client, surgeon, and physician
Client, family, and physician To ensure the success of the care plan, the nurse must involve all necessary parties. It is essential that the client be involved in the client's own health care decisions. The client's family provides needed support, and the physician is essential to provide medical interventions. The hospital director is not necessary for the implementation of the plan of care. A physical therapist and a surgeon are not necessarily involved in every client's care.
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. Research other treatment options available for the client. Remind the client that positive thoughts are essential for recovery. Ask if the client would like to speak with a spiritual adviser.
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? Collaborate with other disciplines to revise the discharge plans. Instruct the client to make alternate living arrangements. Communicate with the physician about additional orders. Inform the family that it is not possible to change the discharge plans.
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 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? 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. Collaborate with the physical therapist to determine the client's ability.
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.
A charge nurse has assigned a new nurse a task that the nurse has not been trained to perform. Which is the most appropriate action for the nurse to take? Consult with the charge nurse before performing the procedure. Review the procedure in the procedure manual before performing the intervention. Perform the procedure and inform the charge nurse of the results. Delegate the intervention to an unlicensed assistive personnel.
Consult with the charge nurse before performing the procedure. Whenever a charge nurse asks a nurse to perform an intervention for which the nurse lacks training or education, the nurse should consult with the charge nurse to determine whether the nurse should attempt to perform the intervention with supervision. Under no circumstances should a nurse attempt to perform interventions beyond the nurse's capacity without supervision, even if instructed to do so by a charge nurse. Delegating the intervention to an unlicensed assistive personnel is not an acceptable option, as the nurse is likely not familiar with the education of this individual.
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. Review the physician's progress notes to determine if any of the tests are not indicated. Instruct the client to refuse the diagnostic tests if the client becomes too fatigued
Coordinate with the other disciplines to schedule the tests with adequate rest for the client. 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.
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? Surveillance Supportive Coordinating Technical
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.
Which are benefits of using the nursing intervention classification (NIC) 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 Justification of the productivity of the nursing staff Determination of which nursing actions the nurse may delegate
Creation of a standardized language Assistance in determining the cost of services that nurses provide Demonstration of the impact of nurses The NIC provides a form of standardized language for use by nurses. Additionally, the NIC helps to expand the knowledge of similarities and differences across nursing diagnoses and explore nursing care information systems. Use of this model aids in determining the costs of services that nurses provide and demonstrating the impact of nurses on overall health care costs. Use of acuity and workload management tools, not the NIC, aids in justifying staffing levels based on productivity. State nurse practice acts, not the NIC, help determine which nursing actions the nurse may delegate.
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? Delay the instruction until the visitors leave. Give the visitors instructions to leave in 10 minutes. 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. 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 an adolescent 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? Delay the instruction until the visitors leave. Give the visitors instructions to leave in 10 minutes. 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. 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 an adolescent 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 cataract surgery. Which should the nurse do first? Determine the client's willingness to follow the regimen. Identify changes from the baseline. 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. 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 the risks and benefits of a blood transfusion with the client. Discuss possible alternatives to a blood transfusion with the physician. 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.
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. Ask the client to discuss the decision with family members. Discuss with the client the reasons for declining surgery. Notify the physician of the client's refusal.
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. Ask the client to discuss the decision with family members. Discuss with the client the reasons for declining surgery. Notify the physician of the client's refusal.
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.
Which is the nurse's priority question to consider prior to delegating a task to an unlicensed assistive personnel (UAP)? Does this task fall within the scope of a UAP? What is the client's condition? How can I supervise the completion of this task? How can I explain the task to the UAP
Does this task fall within the scope of a UAP? 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.
Which action is a nursing intervention that facilitates lifespan care? Educate family members about normal growth and development patterns. Explore factors that could motivate adolescent members of the family to engage in risky behaviors. Identify coping strategies for the family that have worked in the past. Teach contraceptive options for planned pregnancy.
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.
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. Ability of pain medication to be decreased over a designated period of time along with the time frame to be medication free. Length of time between requests for pain medication along with pain scale rating and the amount of medication provided. What techniques have been used to reduce pain outside of pharmacologic modalities as well as how often they are being practiced.
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 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? ffectiveness of intervention including current pain scale, time frame, and client self-report. Ability of pain medication to be decreased over a designated period of time along with the time frame to be medication free. Length of time between requests for pain medication along with pain scale rating and the amount of medication provided. What techniques have been used to reduce pain outside of pharmacologic modalities as well as how often they are being practiced.
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. Perform all care activities for the client to facilitate rest. Teach the family to anticipate the client's needs to care for the client. Arrange with the nurse case manager for an early discharge.
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.
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? Providing medication for agitation Repositioning to prevent pressure injuries Ensuring that the endotracheal tube is secure Changing the dressing to prevent infection
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.
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? Finances of the client The client's condition Time and resources Feedback from the family
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.
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? Go to the client and assess the client's pain. Determine the frequency of pain medication. 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. 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.
Which is an independent (nurse-initiated) action? Executing physician orders for a catheter Meeting with other health care professionals to discuss a client Helping to allay a client's fears about surgery Administering medication to a client
Helping to allay a client's fears about surgery 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, 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? Explain the effects of a high-salt diet and smoking on blood pressure. Identify what barriers the client feels are preventing adherence with the plan. Collaborate with other health care professionals about the client's treatment. 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.
The nurse is preparing a client with a bowel obstruction for emergency surgery. Which intervention has the highest priority for this client? Discuss discharge plans with the client. Inform the client what to expect after the surgery. Instruct the client and family in wound care. Teach the client about dietary restrictions during recovery.
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 statement best explains why continuing data collection is important? It is difficult to collect complete data in the initial assessment. It is the most efficient use of the nurse's time. It enables the nurse to revise the care plan appropriately. It meets current standards of care.
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.
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. Ask the client's family to assist the client in following the plan of care. Provide information to the client on the benefits of complying with the plan of care. Discuss the desired outcomes with the client and the importance of the outcomes.
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.
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. 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. 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.
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? Registered nurse Nursing assistant A senior nursing student present for clinical Licensed practical 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? Registered nurse Nursing assistant who is a nursing student A senior nursing student present for clinical Licensed practical nurse
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 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? Registered nurse Nursing assistant who is a nursing student A senior nursing student present for clinical Licensed practical nurse
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 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? Perform vital signs and blood glucose level. Discuss the need to change positions slowly, especially when moving from sitting to standing. Perform a full review of systems. Initiate an intravenous line and administer 500mL of normal saline.
Perform vital signs and blood glucose level. A client 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.
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? Inform the client that it is not necessary to wash hands before vital signs. Reassure the client that the nurse knows when to perform hand hygiene. Praise the client for taking an active role in the client's care. Tell the client that gloves are required for this procedure. TAKE ANOTHER QUIZ
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.
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? Teach the content again utilizing the same method. 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.
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 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? Teach the content again utilizing the same method. 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.
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? Insert the urinary catheter as ordered to relieve the urinary retention. Reassess whether the client still needs the urinary catheter. Instruct the client that the catheter is essential to check for urinary retention. Inform the client that the catheter will no longer be necessary.
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.
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? Report the findings to the physician for further plans. Reinforce the instructions for the treatment regimen to the client. 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.
Report the findings to the physician for further plans. 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? Revise the care plan to allow the client to ambulate to the bathroom independently. Continue assisting the client to the bathroom to ensure the client's safety. Consult with the physical therapist to determine the client's ability. Instruct the client's family to assist the client to ambulate to the bathroom.
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.
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 Risk factors for and prevention of diabetes mellitus The severity of the client's disease The cellular metabolism of glucose
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 Risk factors for and prevention of diabetes mellitus The severity of the client's disease The cellular metabolism of glucose
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.
As part of a client's plan of care, a nurse teaches a client's spouse how to perform a dressing change to the client's abdominal wound. Which method would be most effective to determine whether the spouse has mastered the skill? Spouse lists the signs of healing. Spouse identifies the steps for the dressing change. Spouse performs the steps of the dressing change correctly. Spouse shows the nurse what supplies are needed.
Spouse performs the steps of the dressing change correctly. The only way to be sure that clients or family caregivers have mastered a skill is watching them perform it. Once the nurse observes them doing a procedure correctly, the nurse can be confident that learning—as well as teaching—has occurred. The other answer options only demonstrate that the spouse has learned the cognitive aspects to related to the skill; the spouse can only demonstrate full, effective knowledge of the skill by performing it.
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 Maintenance Surveillance
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 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? Supportive Surveillance Collaborative Maintenance
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.
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 that the RN will assist the UAP with the client's ambulation. Tell the UAP that a different UAP should ambulate the client. 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 the RN will assist the UAP with the client's ambulation. 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.
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 male. The client is married. The client is blind. The client is an architect. The client denies the need for education.
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 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 client expresses a desire to learn how to manage the medication regime. The parents verbalize acceptance of the need to closely monitor their child's condition. 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.
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 male. The client is married. The client is blind. The client is an architect. The client denies the need for education.
The client is blind 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 client has a diagnosis of Risk for Injury related to falls. How would the nurse know if the intervention was successful? The client calls for assistance to get out of bed. The client is free of falls. The client is taught safety precautions. The client verbalizes risks for injury.
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.
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 asks the nurse to repeat the instructions. 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 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.
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 asks the nurse to repeat the instructions. 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 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 registered nurse is working with an unlicensed assistive personnel. Which client should the nurse not delegate to the unlicensed assistive personnel? The client who needs vital signs taken following infusion of packed red blood cells. The client who requires assistance dressing in preparation for discharge. The client with continuous pulse oximetry who requires pharyngeal suctioning. The client who is pleasantly confused and requires assistance to the bathroom.
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.
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. he client's respiratory rate decreases. The client states, "I can breathe easier now." The client's oxygen saturation level increases. 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. 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.
Which actions are examples of nursing actions listed in the ANA's Nursing: Scope and Standards of Practice for Standard 5: Implementation? Select all that apply. The nurse demonstrates quality by documenting the application of the nursing process in a responsible, accountable, and ethical manner. The nurse incorporates new knowledge to initiate changes in nursing practice if the desired outcomes are not achieved. The nurse develops expected outcomes that provide direction for the continuity of care. The nurse documents implementation and any modifications, including changes or omissions, of the identified plan. The nurse utilizes community resources and systems to implement the plan. The nurse utilizes evidence-based interventions and treatments specific to the diagnosis or problem.
The nurse documents implementation and any modifications, including changes or omissions, of the identified plan. The nurse utilizes community resources and systems to implement the plan. The nurse utilizes evidence-based interventions and treatments specific to the diagnosis or problem. ANA's Nursing: Scope and Standards of Practice for Standard 5 refers to the implementation phase of the nursing process, including documentation of implementation, use of community resources for implementation, and use of evidenced-based interventions. Incorporation of new knowledge refers to Standard 6, Evaluation. Documentation of the plan of care and development of expected outcomes is found in Standards 3 and 4, Outcome Identification and Planning.
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. Which would be the nurse's most appropriate strategy? The nurse encourages the client to take a shower instead of receiving a bed bath. The nurse tells the client that recovery is progressing too slowly. The nurse consults with the health care provider to plan an early discharge. The nurse instructs the family to stop performing tasks for the client.
The nurse encourages the client to take a shower instead of receiving a bed bath. It is important for the nurse to encourage the client to achieve independence in self-care. The nurse would best accomplish this by encouraging the client to gradually do more for oneself. There is no evidence that the client's recovery is progressing too slowly; moreover, this statement would likely come across as critical to the client and would not be constructive, as the nurse does not provide specific recommendations for how the client can improve self-care. Trying to have a client discharged early just so is forced to perform self-care would be inappropriate and possibly even unethical; the client should be discharged when the health care provider believes the client is ready to safely leave the acute care setting. Asking family members to stop assisting the client would also be inappropriate; the client is not fully capable of self-care and will still need the assistance of family. Also, the nurse should communicate the desired outcome directly to the client and work with the client to develop strategies to accomplish the goal.
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 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 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 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 discussing dietary options with a client who is upset due to not being able to have foods the client previously enjoyed. The nurse states, "You may not be able to have steak, but you can have grilled salmon or grilled chicken. Which do you prefer?" What is the purpose for giving the client an option? To help the client adhere to the plan To give the client the opportunity to actively participate in care To save the client the trouble of looking in the menu To encourage the client to make a healthy food choice
To give the client the opportunity to actively participate in care Giving clients options allows them to actively participate in their own care, which is empowering. Although giving the client options might improve the client's adherence to the plan, this is not the primary purpose. The purpose of giving the client options is not to save the client the trouble of looking in the menu or to encourage the client to make a healthy food choice.
A nursing student received a report on his assigned clients for the clinical day. Which client should the student nurse plan to assess first? client who has had an appendectomy and has a temperature of 39.1 degrees C a newly diagnosed client with diabetes who is crying and states "I do not understand how to give my insulin." an asthma client who reports shortness of breath with a respiratory rate of 26 bpm a client who has had a hysterectomy and reports bleeding from the surgical site
an asthma client who reports shortness of breath with a respiratory rate of 26 bpm According to the ABC priority framework, the client who should be assessed first is the asthma client with shortness of breath and a respiratory rate of 26 bpm. The appendectomy client with an elevated temperature should be assessed for suspected infection. However, this is not the priority action. The diabetic client should receive education regarding administration of insulin but this is not a priority. The hysterectomy client should be assessed for possible hemorrhage. However, according to the ABC priority framework, this is not the priority.
A nurse is performing a sterile dressing change on a client's abdominal incision. While establishing the sterile field, the nurse drops the forceps on the floor. The nurse is unable to continue with the dressing change because there are no extra supplies in the room, and no one is present to bring new forceps. The nurse failed to organize: equipment and personnel. environment and client. logistics and planning. skills and assistance.
equipment and personnel. A key component of the organizing interventions is to ensure adequate equipment (extra supplies) and sufficient personnel to assist with more complex tasks. Skills are first learned in nursing school but then validated with policies and procedures of the institution. Assistance is necessary to assist with the skill but is not the main issue in this scenario. Environment would be related to the lighting and space. Client issues would be the correct response if the client was cognitively aware and not confused. Logistics and planning may be related to other issues such as making sure all the elements such as personnel, client, environment, and assistance are all present.
The primary purpose of nursing implementation is to: improve the client's postoperative status. identify a need for collaborative consults. help the client achieve optimal levels of health. implement the critical pathway for the client.
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.
The primary purpose of nursing implementation is to: improve the client's postoperative status. identify a need for collaborative consults. help the client achieve optimal levels of health. implement the critical pathway for the client.
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.
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 manager Nurse case manager Physician Insurance company
nurse case manager 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 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 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.
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 Maintenance Surveillance
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 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? supportive Surveillance Collaborative Maintenance
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.