PrepU Implementing

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 & personnel

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." "The Agency for Healthcare Research and Quality is a resource for evidence-based practice." "Nursing interventions should be supported by a sound scientific rationale."

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

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

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

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

Communicate with the physicians to coordinate their orders.

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

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? Current standards of care Research findings Developmental stage Psychosocial background

Psychosocial background

A nurse in the intensive care unit (ICU) has been assigned to care for a client who was seriously injured during a gang rape. The nurse was raped 6 months ago and fears being too upset to care for the client properly. How should the nurse deal with the assignment? Recognize the nurse's own limitations and ask another nurse to assist if the nurse becomes too emotional. Recognize that the nurse may be faced with this issue again and care for the client. Recognize the nurse's own limitations and ask for another nurse to be assigned. Recognize the 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 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? Tell the client that the physician has ordered sleep medication if necessary. Reschedule the client's bath to the evening shift. Determine whether the nurses have time to give the client's bath at night. Ask the client for permission to give the bath in the morning.

Reschedule the client's bath to the evening shift.

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 Protocol Order set Standing orders

Standing orders

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

The client is free of falls.

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? Instruct the client that some pharmaceutical companies have programs to help with medication expenses. Inform the physician of the need to prescribe a less expensive medication for the client's condition. 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.

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

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 Technical Coordinating

Coordinating

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 Physician Nurse case manager Insurance company

Nurse case manager

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? Ask the ER physician to order IM injections with the new technique. Begin using the technique to determine whether it is effective. Petition to change the protocol based on the new evidence. Research the protocols at other area emergency rooms.

Petition to change the protocol based on the new evidence.

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? Technical skill Interpersonal skill Mechanical skill Intellectual skill

Technical skill

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: nursing interventions. collaborative orders. standing orders. protocols.

standing orders

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). Document client education prior to discharge from the unit. Provide a video demonstration of abdominal wound care.

Creation of a standardized language Assistance in determining the cost of services that nurses provide Demonstration of the impact of nurses

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

The nurse should address the concern with the surgeon.