N400, PrepU for Ch 14 (Implementing)
A client tells the nurse, "My doctor has told me I have to have a blood transfusion, but I am a Jehovah's Witness and I can't take one." What is the nurse's most appropriate intervention? a) Discuss the risks and benefits of a blood transfusion with the client. b) Discuss possible alternatives to a blood transfusion with the physician. c) Discuss the client's options with other church members. d) Discuss the client's refusal with hospital risk managers.
b) Discuss possible alternatives to a blood transfusion with the physician. Explanation: As coordinator of the client's care, the nurse functions as an intermediary between the physician and the client. In order to honor the client's wishes, the nurse would most appropriately consult with the physician to meet the client's physical needs, as well as the client's spiritual needs. The risk and benefits of a blood transfusion are not the relevant issue with the client. Discussing the client's options with other church members would violate the client's privacy and would not meet the client's physical needs. It might be advisable to discuss the client's refusal of care with the hospital risk manager to protect the legal requirements of the institution, but it is not the priority.
As the nurse bathes a patient, she notes his skin color and integrity, his ability to respond to simple directions, and his muscle tone. Which statement best explains why such continuing data collection is so important? a) It meets current standards of care. b) It is the most efficient use of the nurse's time. c) It enables the nurse to revise the care plan appropriately. d) It is difficult to collect complete data in the initial assessment
c) It enables the nurse to revise the care plan appropriately. Explanation: Continuous data collection ensures that the nurse has the most current patient data to evaluate, which allows for updating the care plan as needed. A complete assessment is performed upon admission, but the patient's condition is always changing. The purpose of continued data collection is to provide good patient care; it does not related directly to efficiency of nursing care. While continuous data collection meets standards of care, it is not the primary reason for ongoing assessments.
A nurse who is experienced caring only for well babies is assigned to the newborn intensive care nursery (NICU) because of a shortage of nurses in the NICU. The nurse is assigned to an infant on a ventilator who will require blood transfusions during the shift. What is the nurse's most appropriate course of action? a) The nurse should recognize the necessity of the assignment and provide care to the best of her ability. b) The nurse should request that the blood transfusions be delayed until the next shift. c) The nurse should inform the charge nurse that she does not have the experience to properly care for this client. d) The nurse should ask another nurse who was previously assigned to the client for instruction.
c) The nurse should inform the charge nurse that she does not have the experience to properly care for this client. Explanation: The nurse should recognize that she 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 client is in a rehabilitation unit after a traumatic brain injury. In order to facilitate the client's recovery, what would be the nurse's most appropriate intervention? a) Arrange with the nurse case manager for an early discharge. b) Teach the family to anticipate the client's needs to care for the client. c) Perform all care activities for the client to facilitate rest. d) Encourage the client to provide as much self-care as possible.
d) Encourage the client to provide as much self-care as possible. Explanation: The nurse must encourage the client to provide as much self-care as possible in order to achieve the highest level of independence. Performing all care activities for the client makes the client dependent on the nurse. If the family anticipates and meets all the client's needs, this also hinders the client's recovery. An early discharge is not indicated because the client must be sufficiently recovered.
A nurse suspects that the client with Crohn's disease does not understand the medication regimen or diet modifications required to manage the illness. What is the nurse's most appropriate action? a) Ask the client to verbalize the medication regimen and diet modifications required. b) Refer the client to available community resources and support groups. c) Ask the nutritionist to give the client strict meal plans to follow. d) Ask the gastroenterologist to explain the treatment plan to the client and family again.
a) Ask the client to verbalize the medication regimen and diet modifications required. Explanation: If the nurse suspects a client does not understand instructions, the first step is to assess the client's understanding. The most effective way to do that is to have the client repeat his understanding of the instructions. The other steps might be interventions that the nurse would institute after determining the client's needs.
A client cannot afford the treatment prescribed. Who would be the most appropriate professional for the nurse to involve with the client's care? a) Insurance company b) Nurse case manager c) Physician d) Nurse manager
b) Nurse case manager Explanation: The nurse case manager is the expert on resources available for the client's care. The nurse manager is responsible for the operation of the nursing unit. The physician is concerned with the client's medical needs. The insurance company is a possible resource, if the client has insurance coverage.
A client in the last stages of pancreatic cancer tells the nurse, "I am tired of fighting. I am ready to die." What is the nurse's best action? a) Collaborate with other disciplines to plan end-of-life care for the client. b) Research other treatment options available for the client. c) Ask if the client would like to speak with a spiritual adviser. d) Remind the client that positive thoughts are essential for recovery.
a) Collaborate with other disciplines to plan end-of-life care for the client. Explanation: 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.
The nurse is caring for a client who is recovering from a cerebrovascular accident (CVA). When reviewing the client's orders, the nurse notes that one of the physicians wrote orders to ambulate the client while another physician ordered strict bed rest for the client. How would the nurse most appropriately remedy this conflict? a) Communicate with the physicians to coordinate their orders. b) Instruct the client to ask the physicians for clarifications of instructions. c) Assess the client to determine if the client is capable of ambulation. d) Collaborate with the physical therapist to determine the client's ability.
a) Communicate with the physicians to coordinate their orders. Explanation: As coordinator of care, the nurse is responsible for ensuring the continuity of the treatment plan. If conflicts occur in the treatment plan, the nurse first consults with the physicians who have written the conflicting orders. The nurse may assess the client to determine if the client is capable of ambulation, but this does not resolve the conflict nor determine if 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 physician's 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? a) Delay the instruction until the visitors leave. b) Leave written information for the client to read later. c) Give the visitors instructions to leave in 10 minutes. d) Ask the client if the client has any questions.
a) Delay the instruction until the visitors leave. Explanation: The nurse must take into consideration the client's developmental level and willingness to participate in care in order to successfully implement the plan of care. The client is a teenager and socialization with a peer group is essential, so the nurse would most appropriately wait until the visitors left. 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 has prepared to educate a client about caring for a new colostomy. When the nurse begins the instruction, the client states, "I am not ready to deal with this now. I am feeling overwhelmed." What is the nurse's most appropriate action? a) Discontinue the education and attempt at another time. b) Continue the education and remind the client that it is essential to learn self-care. c) Discontinue the education and ask the client for permission to teach a family member. d) Medicate the client for anxiety and continue the education later.
a) Discontinue the education and attempt at another time. Explanation: The nurse should always perform client education when the client is receptive of the education. The client verbalizes not being ready to learn, so education should be discontinued and continued at another time. Asking for permission to teach a family member does not encourage the client to learn self-care and acquire independence. The client does not need medication for anxiety at this time. This is a normal reaction. It would not be productive to continue the education because the client is not ready to learn.
A nurse is performing a sterile dressing change on a client's abdominal incision. While establishing the sterile field, the nurse drops the forceps on the floor. The nurse is unable to continue with the dressing change because there are no extra supplies in the room, and no one is present to bring new forceps. Which has the nurse failed to organize? a) Equipment and personnel b) Skills and assistance c) Logistics and planning d) Environment and client
a) Equipment and personnel Explanation: A key component of the organizing interventions is to ensure adequate equipment (extra supplies) and sufficient personnel to assist with more complex tasks.
The nurse is to delegate certain tasks to unlicensed assistive personnel (UAP). Which of the following tasks can be appropriately assigned to a UAP? a) Provide client assistance to the bedside commode. b) Reassess the client's sacrum for redness when doing bed bath. c) Secure the client's jewelry before surgery. d) Request the UAP to get the unit of blood from the blood bank.
a) Provide client assistance to the bedside commode. Explanation: Assisting with toileting is one of the tasks permitted by the state board of nursing for UAP. This task is commonly performed by UAP in health facilities.
A client recovering after an appendectomy is reporting pain. The nurse administers the ordered pain medication and assists the client to splint the incision. What is the nurse's next step in implementing the plan of care? a) Reassess the client to determine the effectiveness of the interventions. b) Instruct the client that pain medication is available at regular intervals. c) Notify the physician that the client has required pain medications. d) Perform additional non-pharmacologic pain interventions.
a) Reassess the client to determine the effectiveness of the interventions. Explanation: After implementing any interventions (such as pain medication) or any nonpharmacologic pain control method (such as splinting the incision) the nurse must always reassess the client to determine the effectiveness of the interventions. If the interventions are ineffective, the plan is revised and additional interventions are planned.
The nurse is discussing diabetes mellitus with the family members of a client recently diagnosed. In order to promote the health of the family members, what would be the most important information for the nurse to include? a) Risk factors and prevention of diabetes mellitus b) The severity of the client's disease c) The cellular metabolism of glucose d) Medications used to treat diabetes mellitus
a) Risk factors and prevention of diabetes mellitus Explanation: An important nursing function is to enable clients to prevent illness. Since 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 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 working with Ms. V. today. Ms. V. is having a difficult time accepting her new diagnosis of type 2 diabetes. Thenurse pulls up a chair next to Ms. V.'s bed and holds her hand while listening to her story. What type of nursing intervention is the nurse engaging in? a) Supportive intervention b) Coordinating intervention c) Psychosocial intervention d) Supervisory intervention
a) Supportive intervention Explanation: Supportive interventions emphasize use of communication skills, relief of spiritual distress, and caring behaviors. Psychosocial interventions focus on resolving emotional, psychological, or social problems. Coordinating interventions involve many different activities, such as acting as a client advocate and making referrals for follow-up care. Supervisory interventions refer to overseeing the client's overall health care.
The nurse caring for a client who is recovering after a motor vehicle accident is planning for the client to begin increasing responsibility for self-care. What would be the nurse's most appropriate strategy? a) The nurse encourages the client to take a shower instead of receiving a bed bath. b) The nurse instructs the family to stop performing tasks for the client. c) The nurse consults with the physician to plan an early discharge. d) The nurse tells the client that recovery is progressing too slowly.
a) The nurse encourages the client to take a shower instead of receiving a bed bath. Explanation: 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 himself. There is no evidence that the client's recovery is progressing too slowly. There is no indication that an early discharge would be beneficial for the client. There is also no indication that the family is doing too much for the client. The client is not fully capable of self-care and will still need the assistance of family.
Which nursing action can be categorized as a surveillance or monitoring intervention? a) auscultating of bilateral lung sounds b) use of therapeutic communication skills c) administering paracetamol tablet d) providing hygiene
a) auscultating of bilateral lung sounds Explanation: Surveillance or monitoring nursing interventions includes 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.
The nurse is caring for a vegetarian who is suffering from iron deficiency anemia. The nutritional plan for a client with anemia calls for the client to increase consumption of animal protein. How will the nurse plan to meet this client's nutritional needs? a) Meet with the client's family to emphasize the importance of nutritional modification. b) Collaborate with the nutritionist to modify the nutritional plan. c) Instruct the client that consumption of animal protein is necessary to cure the anemia. d) Arrange for animal protein to be disguised in the client's meal.
b) Collaborate with the nutritionist to modify the nutritional plan. Explanation: A vegetarian does not consume animal proteins. While animal proteins are an important source of iron, plant proteins are available. To honor the preferences of the client, the nurse would collaborate with the nutritionist to include these plant sources of protein in the client's diet (instead of the animal protein). It is not true that the client has to consume animal protein to cure the anemia. Meeting with the client's family would be inappropriate because this would violate the wishes of the client. Arranging for animal protein to be disguised in the client's meal would violate the client's trust and would also not be effective in the long term after the client has been discharged.
During morning report, the night nurse tells the oncoming nurse that the client has been medicated for pain and is resting comfortably. Thirty minutes later, the client calls and requests pain medication. What is the nurse's appropriate first action? a) Determine the frequency of pain medication. b) Go to the client and assess the client's pain. c) Medicate the client with the ordered pain medication. d) Instruct the client in nonpharmacologic pain management.
b) Go to the client and assess the client's pain. Explanation: The nurse's first action should always be to determine the cause of the client's pain in order to determine the correct intervention. After determining the cause, the nurse can plan how to proceed. The other steps would be appropriate, but only after the assessment.
The nurse is assigned a client who had an uneventful colon resection two days ago and requires a dressing change. To which nursing team member should the nurse avoid delegating the dressing change? a) Licensed practical nurse b) Nursing assistant c) Registered nurse d) A senior nursing student present for clinical
b) Nursing assistant Explanation: The nurse should avoid delegating the dressing change to the nursing assistant. The dressing change would be within the scope of practice of the registered nurse, licensed practical nurse, and the senior nursing student but not the nursing assistant.
A nurse in the ICU (intensive care unit) has been assigned to care for a client who was seriously injured during a gang rape. The nurse was raped 6 months ago and feels that she will be too upset to care for the client properly. How should the nurse deal with the assignment? a) Recognize that she may be faced with this issue again and care for the client. b) Recognize her limitations and ask for another nurse to be assigned. c) Recognize the issue and care for the client to the best of her ability. d) Recognize her limitations and ask another nurse to assist her if she becomes too emotional.
b) Recognize her limitations and ask for another nurse to be assigned. Explanation: The nurse should keep the client's best interests in mind. If the nurse feels that her emotional state would compromise the client's care, the best course would be for the nurse to request a different assignment. The other courses of action leave the possibility that the client's care could be compromised.
The nurse is caring for a 10-year-old client who is newly diagnosed with a seizure disorder. What variable would alter the nurse's plan for educating the client and parent? a) The parents verbalize acceptance of the need to closely monitor their child's condition. b) The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years. c) The client expresses a desire to learn how to manage the medication regime. d) The parents have comprehensive insurance coverage for their family's medical care.
b) The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years. Explanation: If the family has experience caring for a child with a seizure disorder, the family would already have some basic knowledge, so the nurse would address the education differently. The client expressing a desire to learn indicates receptiveness to the education. The parents' acceptance of their child's condition indicates that they are ready to begin dealing with the child's condition. The fact that the child has comprehensive insurance coverage is a strength that will make options available to the family, but will not necessarily change the nurse's educational plan.
The client is having difficulty breathing. The respiratory rate is 44 and the oxygen saturation is 89% (0.89 L). The nurse raises the head of the bed and applies oxygen at 3 L/min per nasal cannula. How does the nurse determine the effectiveness of the interventions? Select all that apply. a) The client is watching television. b) The client's respiratory rate decreases. c) The client states, "I can breathe easier now." d) The client's family asks if the client is going to be okay. e) The client's oxygen saturation level increases.
b) The client's respiratory rate decreases. c) The client states, "I can breathe easier now." e) The client's oxygen saturation level increases. Explanation: When reassessing the client after implementing interventions to increase oxygenation, the nurse would look for a decrease in respiratory rate to 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.
An 84-year-old male has been admitted to the hospital several times in the past few months for exacerbations of chronic obstructive pulmonary disease (COPD) and elevated blood glucose. Which statement by the client could help identify the most likely reason for the changes in his health status? a) "I asked my neighbors to help me with my yard work." b) "I sort my medication into an organizer every week." c) "My wife's been gone for about 7 months now." d) "My daughter has been staying with me the past few weeks."
c) "My wife's been gone for about 7 months now." Explanation: The client's loss may be affecting how he is able to provide self-care. Emotionally, he may be depressed and questioning the benefits of his health care regimen, or he may have depended on his wife to help with his health care and not have the ability to take care of himself. Assessment of the client allows the nurse to alter the plan of care to meet his needs. The statements concerning having a family member staying with him, having help with the yard work, and sorting medications into an organizer should be explored, but do not reflect the same emotional impact on the client's life as the loss of a spouse.
The nurse is caring for a client admitted to the hospital for renal calculi. What is the action to take first? a) Diet as tolerated. b) Force fluids by mouth. c) Assess for bladder distention. d) Strain urine after each void.
c) Assess for bladder distention. Explanation: 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; this could potentially cause the client discomfort and harm.
Discharge plans for a client with a mental health disorder include living with family members. The nurse learns that the family is no longer willing to allow the client to live with them. What is the nurse's most appropriate action? a) Communicate with the physician about additional orders. b) Inform the family that it is not possible to change the discharge plans. c) Collaborate with other disciplines to revise the discharge plans. d) Instruct the client to make alternate living arrangements.
c) Collaborate with other disciplines to revise the discharge plans. Explanation: The discharge needs of this client are complicated and the nurse will need the assistance of other disciplines to make a successful discharge plan. The client should have input into the future living arrangements, but the client does not have the resources to make the arrangements alone. The physician may be involved in the discharge plan, but additional orders are not necessary. It is not true (and would be inappropriate) to tell the family that discharge plans cannot be changed. If the family is unwilling to take the client, the placement will be unsuccessful.
The mother of a pediatric client being discharged confides to the nurse that her husband is abusive and she is afraid to return home. What is the nurse's most appropriate action? a) Arrange for a counseling session for the parents of the client. b) Give the mother telephone numbers of women's shelters. c) Coordinate with the case manager to make a safe discharge plan. d) Advise the mother that she should report her concerns to the police.
c) Coordinate with the case manager to make a safe discharge plan. Explanation: The nurse's top priority is the safety of the client. The person most qualified to consider the options available to protect the mother and client is the case manager. It is not sufficient to simply give the mother telephone numbers of women's shelters. This does not take into account the possible needs of the child after discharge. Advising the mother that she should report concerns to the police does not address the discharge needs of the client. Arranging a counseling session does not meet the immediate discharge needs of the client.
The nurse is preparing a client with a bowel obstruction for emergency surgery. Of the following interventions, which has the highest priority? a) Discuss discharge plans with the client. b) Teach the client about dietary restrictions during recovery. c) Inform the client what to expect after the surgery. d) Instruct the client and family in wound care.
c) Inform the client what to expect after the surgery. Explanation: If the surgery is an emergency, the highest priority is to meet the client's immediate needs. The nurse should inform the client about what to expect after surgery. Discussing discharge plans, instruction in wound care, and dietary restrictions are important, but not necessary before the surgery.
The nurse is caring for Mr. M., a 48-year-old man with congestive heart failure. The nurse manager informs the nurse that Mr. M. was enrolled in a clinical trial to assess whether a 10-minute walk, 3 times per day, leads to expedited discharge. Which type of evaluation best describes what the researchers are examining? a) Structure evaluation b) Cost-effectiveness evaluation c) Outcome evaluation d) Process evaluation
c) Outcome evaluation Explanation: An outcome evaluation determines the extent to which a client's behavioral response to a nursing intervention reflects the outcome criteria.
The nurse has instructed the client in self-catheterization, but the client is unable to perform a return demonstration. What is the nurse's most appropriate plan of action? a) Revise the plan to include the inclusion of a support group. b) Teach the content again utilizing the same method. c) Reassess the appropriateness of the method of instruction. d) Report the client's inability to learn to the case manager.
c) Reassess the appropriateness of the method of instruction. Explanation: It is the nurse's responsibility to revise the plan of care if an intervention is not successful. The most appropriate action of the nurse would be to determine if the initial education was the most effective for this client. Simply teaching the content again without reassessing the client's needs would not necessarily be effective. A support group might be helpful, but not until the client's needs are evaluated. The case manager is not responsible for the client's learning.
Mr. J. is a 56-year-old man status post admission for a myocardial infarction and coronary artery bypass graft. He is preparing to go home tomorrow. Mr. J. expresses that he feels unprepared to cook heart-healthy foods. The nurse sits with Mr. J. and reviews the heart-healthy nutrition plan, asking him to identify which foods would be appropriate for him to eat. What type of nursing intervention is the nurse engaging in? a) Supportive intervention b) Coordinating intervention c) Supervisory intervention d) Educational intervention
c) Supervisory intervention Explanation: The nurse is supervising the client's skill performance with regard to assuming responsibility for the self-management of his diet.
The nursing student is preparing to ambulate an obese client. The RN is concerned about the student's ability to safely ambulate the client. What would be the nurse's most appropriate action? a) Tell the student not to ambulate the client at this time. b) Tell the student that the nursing assistant should ambulate the client. c) Tell the student that the RN will assist the student with the client's ambulation. d) Tell the student to ask the client if the client is comfortable with the student assisting ambulation.
c) Tell the student that the RN will assist the student with the client's ambulation. Explanation: The client's safety is always the nurse's primary concern. If the nurse feels there is a possibility for injury to the client, one strategy to prevent it is to offer assistance. By the nurse assisting the student, client safety is assured while still allowing the student to learn. Having the nursing assistant ambulate the client or instructing the student not to ambulate the client does not assist the student's learning. Asking the client if the client feels comfortable is inappropriate.
When the nurse is administering medication, an older adult client states, "Why does everyone keep asking my name? I've been here for days." How should the nurse respond to the client? a) "It is a hospital policy to reduce the potential for errors." b) "We ask your name to ensure that we are treating the right client." c) "It is a habit that nurses develop in school." d) "We ask your name to show that we respect your rights."
d) "We ask your name to ensure that we are treating the right client." Explanation: The primary reason for asking the client to state her name is to ensure that the nurse is dealing with the correct client. Asking the client to state her 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 her name, but it is a step that is used in all client care situations. Respecting clients' rights is important but that is not why nurses ask for their names.
The nurse is preparing to administer a blood pressure medication to a client. To ensure the client's safety, what is the priority action for the nurse to take? a) Determine the client's reaction to the medication in the past. b) Tell the client to report any side effects experienced. c) Ask the client to verbalize the purpose of the medication. d) Assess the client's blood pressure to determine if the medication is indicated.
d) Assess the client's blood pressure to determine if the medication is indicated. Explanation: Before initiating any intervention, the nurse must determine if the intervention is still necessary. Before administering blood pressure medication, the blood pressure must be assessed. The client's reaction to the medication previously does not indicate if the medication is indicated at this time. The client's ability to verbalize the purpose of the medication is important to promote self-care, but it is not important for the client's safety at this time. The client's report of side effects would indicate an adverse reaction after the medication is administered, but it would not protect the client's safety before the medication was given.
Priority setting is based on the information obtained during reassessment. Priority setting is used to rank nursing diagnoses. Each of the following contributes to priority setting except which of the following? a) The client's condition b) Time and resources c) Feedback from the family d) Finances of the client
d) Finances of the client Explanation: Each of these factors contributes to the prioritization of nursing diagnoses except the client's finances. The nursing code of ethics states that clients receive the same treatment regardless of their ability to pay.
The nurse is coordinating care for the client with continuous pulse oximetry who requires pharyngeal suctioning. Which staff member should the nurse avoid delegating the task of suctioning? a) A senior nursing student present for clinical b) Registered nurse c) Licensed practical nurse d) Nursing assistant who is a nursing student
d) Nursing assistant who is a nursing student Explanation: The nurse should avoid delegating this client to the nursing assistant. Suctioning and the association evaluation of the client would be within the scope of practice of the registered nurse, licensed practical nurse, and the senior nursing student but not the nursing assistant.
The nurse is preparing to give the client a bath early in the morning. The client states, "I prefer to take my bath at night. It helps me sleep." What is the nurse's most appropriate action? a) Ask the client for permission to give the bath in the morning. b) Determine if the nurses have time to give the client's bath at night. c) Tell the client that the physician has ordered sleep medication if necessary. d) Reschedule the client's bath to the evening shift.
d) Reschedule the client's bath to the evening shift. Explanation: The client's preferences are a primary consideration in scheduling interventions. The client's preference to have a bath at night requires a change in scheduling. Asking for permission to give the bath in the morning does not address the client's preference. The schedule of the nurses should not take priority over client needs. Informing the client about sleep medication does not address the client's preference.
The nurse is caring for a postoperative client who is receiving morphine sulfate for pain management. The nurse obtains the following vital signs. HR 74 RR 8 BP 114/68. After reviewing the nursing care plan and physician orders, the nurse administers naloxone (Narcan). What would allow the nurse to initiate this action? a) Protocol b) Order set c) Algorithm d) Standing orders
d) Standing orders Explanation: Standing orders allow the nurse to initiate action that ordinarily require the order of a physician, such as administer naloxone. An algorithm is a binary decision tree that guides stepwise assessment and intervention for a high-risk subgroup of clients. A protocol is a written plan that details nursing activities to be executed in specific situations. An order set is a preprinted set of provider orders that expedite the provider order process.
Nurse Mayweather is auscultating lung sounds. She notes crackles in the LLL which were not present at the start of the shift. Nurse Mayweather is engaged in which type of nursing intervention? a) Maintenance intervention b) Educational intervention c) Psychomotor intervention d) Surveillance intervention
d) Surveillance intervention Explanation: Surveillance interventions include detecting changes from baseline data and recognizing abnormal response. Nurses rely on the senses to detect changes: observing the appearance and characteristics of clients; hearing by auscultation, pitch, and tone. Nurses use these surveillance activities to determine the current status of clients and changes from previous states.
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) a client who has had an appendectomy and has a temperature of 39.1 degrees C b) a newly diagnosed client with diabetes who is crying and states "I do not understand how to give my insulin." c) a client who has had a hysterectomy and reports bleeding from the surgical site d) an asthma client who reports shortness of breath with a respiratory rate of 26 bpm
d) an asthma client who reports shortness of breath with a respiratory rate of 26 bpm Explanation: 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.
