Nurs 211 Chapter 17: Implementing

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

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

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

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

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

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

Which 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

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

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

Discontinue the education and attempt at another time.

A nurse is caring for a postoperative client who reports a pain level of 6 on a scale from 1 to 10. After administering the prescribed pain medication, which intervention should the nurse include in the nursing care plan to monitor and evaluate pain? Assess nonpharmacologic modalities used to reduce pain. Implement the ABC guide of pain management. Ambulate the client after administration of pain medication. Review client goals for comfort.

Implement the ABC guide of pain management.

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

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 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

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

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

Which is is the priority activity for the nurse to perform in the implementation step of the nursing process? -Reassess client's needs. -Document nursing care. -Prioritize evaluation of care. -Differentiate between subjective and objective data.

Reassess client's needs.

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

Surveillance

After learning about a client's limited financial resources and limited insurance benefits, the home care nurse modifies nursing interventions related to a client's care instructions. The nurse modifies the plan of care based upon which client variable? -Psychosocial background -Developmental stage -Research findings -Current standards of care

Psychosocial background

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

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

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 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.

Before implementing any intervention, which questions should the nurse ask oneself? Select all that apply. "Is the client prepared for what needs to be done?" "Do I have all the necessary supplies and equipment needed?" "Do I have the skills to perform the intervention?" "Can I do the intervention alone or do I need help?" "Have I obtained permission from the physician to perform this intervention?"

"Is the client prepared for what needs to be done?" "Do I have all the necessary supplies and equipment needed?" "Do I have the skills to perform the intervention?" "Can I do the intervention alone or do I need help?" "Have I obtained permission from the physician to perform this intervention?"

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

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

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

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

A nurse is developing a plan of care for a client and determines appropriate outcomes and interventions for this client. Which variable would be most appropriate for the nurse to address to ensure that the care plan meets the client's needs? Select all that apply. Client's ability to participate Client's developmental stage Client's cultural background Client's socioeconomic status Client's gender

Client's ability to participate Client's developmental stage Client's cultural background Client's socioeconomic status

The nurse assigned to care for a client who has received a sedative has asked the unlicensed assistive personnel (UAP) to help the client to the toilet. The nurse demonstrates proper delegation skills by performing which actions? Select all that apply. Confirming that the UAP has successfully passed this skill competency Being available for questions from the UAP Giving a report on the client to the UAP and answering questions Transferring accountability and responsibility for the client to the UAP Confirming that the UAP has repeatedly completed similar tasks

Confirming that the UAP has successfully passed this skill competency Being available for questions from the UAP Giving a report on the client to the UAP and answering questions Confirming that the UAP has repeatedly completed similar tasks

The 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.

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

Which action is a responsibility of the nurse in the nurse-nurse team relationship? Provide creative leadership to make the nursing unit a challenging place to work. Communicate nursing's perspective regarding the client and family. Challenge the client to develop self-care abilities that promote health. Intervene to promote healthy family functioning through education and advocacy.

Provide creative leadership to make the nursing unit a challenging place to work.

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

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

The client reports right knee pain of 6/10 on the pain scale and requests medication. The nurse assesses and flushes the intravenous site. Which type of intervention skill is the nurse using? -Interpersonal skill -Intellectual skill -Technical skill -Mechanical skill

Technical Skill

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 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.

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 nursing team, consisting of a nurse and experienced unlicensed assistive personnel (UAP), have worked well together for the past year. The nurse instructs the UAP to feed a stable stroke client, assist with dressing a client in preparation for discharge, and take vital signs of a third client in addition to notifying the nurse if the blood pressure becomes low. Which error has the nurse made? -The nurse failed to communicate clear instructions regarding what constitutes a low blood pressure. -The nurse delegated tasks to the UAP that are outside the scope of that person's preparation. -The nurse failed to validate the UAP's knowledge and skill to perform the tasks. -The nurse delegated too many tasks to the unlicensed assistive personnel.

The nurse failed to communicate clear instructions regarding what constitutes a low blood pressure.

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

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

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

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.

What is the priority goal of interventions for a risk diagnosis? Reduce or eliminate contributing factors Prevent an actual problem Collect additional data Promote higher level wellness

Prevent an actual problem

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

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

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."

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

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

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.

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.

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

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

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

A dependent nursing intervention, because oxygen is considered a drug that requires a physician's order

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.

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

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

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.

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.

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.

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? Reassess the client to determine the effectiveness of the interventions. Instruct the client that pain medication is available at regular intervals. Notify the physician that the client has required pain medications. Perform additional nonpharmacological pain interventions.

Reassess the client to determine the effectiveness of the interventions.

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

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

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

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

A client being treated for myasthenia gravis at home tells the nurse, "This medicine is so expensive. I have only been taking half of what the doctor ordered." How would the nurse mosteffectively meet this client's need? -Collaborate with other disciplines to determine the best way to meet the client's medication requirements. -Reinforce to the client and family the necessity of taking all medication as ordered to stabilize the client's condition. -Inform the physician of the need to prescribe a less expensive medication for the client's condition. -Instruct the client that some pharmaceutical companies have programs to help with medication expenses.

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

A client in the last stages of pancreatic cancer tells the nurse, "I am tired of fighting. I am ready to die." What is the nurse's best action? -Collaborate with other disciplines to plan end-of-life care for the client. -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.

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

Communicate with the physician for additional orders.

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.

A client on the medical-surgical unit is scheduled for several diagnostic tests. The nurse is concerned that the tests will be too tiring for the client. What would be the nurse's mostappropriate action? 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.

Which are appropriate guidelines for the nurse to follow when delegating tasks to an unlicensed assistive personnel (UAP)? Select all that apply. Delegate tasks that are within the UAP's scope of practice. Delegate tasks that involve minimal risk. Provide appropriate supervision when delegating tasks. Provide feedback to the UAP after the task is completed. Delegate correctly to avoid the UAP asking questions about the task.

Delegate tasks that are within the UAP's scope of practice. Delegate tasks that involve minimal risk. Provide appropriate supervision when delegating tasks. Provide feedback to the UAP after the task is completed.

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.

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.

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.

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

Does this treatment make sense for this client?

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

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

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

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

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.

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

Model self-care behaviors for the client.

A client is diagnosed with hypertension, placed on a low-sodium diet, and given smoking cessation literature. The nurse observes the client eating from a fast food restaraunt bag that a family member brought in and the client states, "I don't think I can do this." What is the nurse's first objective when implementing care for this client? -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 is preparing a client to be discharged from the surgical unit following abdominal surgery. Which intervention will the nurse use to ensure the client understands proper wound care techniques? -Include family members or other caregivers in the education. -Delegate teaching to unlicensed assistive personnel (UAP). -Provide a video demonstration of abdominal wound care. -Document client education prior to discharge from the unit.

Include family members or other caregivers in the education.

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.

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.

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 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 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 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

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.

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

Personnel

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

Petition to change the protocol based on the new evidence.

Which nursing interventions are appropriate to perform when addressing a risk nursing diagnosis? Select all that apply. Prevent the problem. Reduce or eliminate risk factors. Monitor the client's status. Promote a higher level wellness. Collect additional data to rule out the diagnosis.

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

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

Provide the client with assistance in transferring to the bedside commode

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

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

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

Psychosocial Supportive Physical

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

Reassess the client to determine whether the action is needed.

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

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

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

Right Circumstance

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.

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

Standing Orders

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

Standing Orders

The client is having difficulty breathing. The respiratory rate is 44 and the oxygen saturation is 89% (0.89 L). The nurse raises the head of the bed and applies oxygen at 3 L/min per nasal cannula. How does the nurse determine the effectiveness of the interventions? Select all that apply. The client's 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.

Which examples are essential components for delegating nursing care to an unlicensed assistive personnel (UAP)? Select all that apply. The UAP has sufficient knowledge and skill for completing the task. The nurse has clearly communicated instructions to the UAP. The UAP can verbalize what information to report to the nurse. The nurse seeks input from the UAP in planning the client's care for the shift. The UAP evaluates the client's response after implementing the task and then reports findings to the nurse

The UAP has sufficient knowledge and skill for completing the task. The nurse has clearly communicated instructions to the UAP. The UAP can verbalize what information to report to the nurse.

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 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.

When caring for a client in the emergency room who has presented with symptoms of a myocardial infarction (MI), the nurse orders laboratory tests and administers medication to the client before the physician has examined the client. For the nurse to be operating within the nurse's scope of practice, what conditions must be present? -The nurse is using the standards of care for clients with MIs. -The nurse is operating under standing orders for clients with suspected MIs. -The nurse is experienced in the needs of clients with MIs. -The nurse is ordering what the physician usually orders.

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

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

The nurse should address the concern with the surgeon.

A nurse who is experienced caring only for well babies is assigned to the neonatal intensive care unit (NICU) because of a shortage of nurses in the NICU. The nurse is assigned to an infant on a ventilator who will require blood transfusions during the shift. What is the nurse's mostappropriate course of action? -The nurse should 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 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

What are the goals of the research that is behind the Nursing Outcomes Classification (NOC) system? Select all that apply. To identify, label, and validate nursing-sensitive client outcomes and indicators To teach decision making To ensure appropriate reimbursement for nursing services To communicate nursing to non-nurses To evaluate the validity and usefulness of the classification in clinical field testing To define and test measurement procedures for the outcomes and indicators

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

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.