139 Chapter 18 Questions

1. A client being prepared for discharge to home will require several interventions in the home environment. The nurse informs the discharge planning team—consisting of a home health care nurse, physical therapist, and speech therapist—of the client's discharge needs. This interaction is an example of which professional nursing relationship? A. Nurse-health care team B. Nurse-client C. Nurse-client-family D. Nurse-nurse

A Rationale: A nurse-health care team professional relationship occurs when the nurse coordinates the input of the multidisciplinary team into a comprehensive plan of care. The nurse may also serve as a liaison between the client and family and the health care team, as necessary. The nurse is the leader of the team, which includes three other disciplines involved in the health care of the client and not just the client, the client's family, or another nurse. Question format: Multiple Choice Chapter 18: Implementing Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 477

35. A nurse enters the room of a client in preparation for changing the dressing on a client's infected leg wound. Which action does the nurse perform before initiating the procedure? A. Reassess the client to determine the client's status and needs. B. Ensure that all equipment and supplies are available. C. Announce to the client that it's time for the dressing to be changed. D. Prepare to modify the dressing change procedure due to limited time available.

A Rationale: Although it would be important to be organized and have all supplies and equipment readily available, the nurse should, before implementing any nursing action, reassess the client to determine their status and whether the action is still needed. Modifying the procedure because of the lack of time would be improper. The nurse should work in partnership with the client and mutually work together to establish a dressing change schedule that meets the client's needs. Announcing that it's time for the dressing change does not allow the client's participation in decision-making about care. Question format: Multiple Choice Chapter 18: Implementing Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 477

7. Which factor should the nurse most consider when determining which interventions would best meet the needs of a client? A. The client's response to health and illness B. The client's psychosocial health C. The client's compliance with the treatment regimen D. The client's response to selected aspects of the treatment plan

A Rationale: In all nurse-client interactions, the nurse should be concerned with the client's response to health and illness and the client's ability to meet basic human needs. Nurses should be concerned with how the client is responding to the plan of care in general and not just the client's psychosocial needs or compliance to the treatment regimen. Other health care professionals focus only on selected aspects of the client's treatment regimen. Question format: Multiple Choice Chapter 18: Implementing Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 475

3. Adherence to defined principles is recommended when delegating care tasks to assistive personnel. According to these principles, who is responsible and accountable for nursing practice? A. The registered nurse B. The American/Canadian Nurses Association C. The nurse manager D. The unit's medical director

A Rationale: It is the registered nurse who is responsible and accountable for nursing practice. The nurse manager is responsible for actions and documentation of the nurse. The unit's medical director is not involved in the nursing practices. The American/Canadian Nurses Association are national professional associations representing nurses in either the United States or Canada. These associations advance the practice and profession of nursing to improve health outcomes. Question format: Multiple Choice Chapter 18: Implementing Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 491

32. The nurse is assessing a client with a diagnosis of hypertension. The client's blood pressure is 178/88 mm Hg, an increase from 134/78 mm Hg at the previous clinic visit. The nurse asks the client what has changed from the previous visit. Which client statement identifies a potential factor interfering with the plan of care? A. "My grandchildren have moved in with us while their parents are going through financial difficulties." B. "I am taking a cooking class at the community college to learn new healthy cooking techniques." C. "We moved to a new neighborhood that has several walking trails, but they are all uphill and really difficult." D. "My son gave me a blood pressure machine to monitor my blood pressure at home, and I use it every day."

A Rationale: Many physical, emotional, social, and environmental factors can affect the client's health status and self-care behaviors. In this case, having the grandchildren move in due to financial hardships can be stressful, which would raise the client's blood pressure. Having new healthy cooking techniques, walking more (even if it is uphill and difficult), and home monitoring of blood pressure are all health-promoting activities, which should help to lower blood pressure. Question format: Multiple Choice Chapter 18: Implementing Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 487

4. A client is receiving care on a rehabilitative medicine unit during recovery from a stroke. The client voices frustration that the physical therapist, occupational therapist, neurologist, primary care physician, and speech language pathologist "don't seem to be on the same page" and that "everyone has their own plan for me." How can the nurse best respond to the client's frustration? A. Facilitate communication between the different professionals and attempt to coordinate care. B. Educate the client about the unique scope and focus of each member of the health care team. C. Modify the client's plan of care to better reflect the commonalities between the different disciplines. D. Arrange for all professionals to perform bedside assessments and interventions simultaneously, rather than individually.

A Rationale: Nurses play a pivotal role in the coordination of care and often need to facilitate communication between members of different disciplines. Educating the client about the role of each professional may be useful, but it does not achieve coordination of care. Similarly, amending the client's plan of care will not create unity and collaboration. It is unrealistic to expect all members of the care team to always visit simultaneously. Question format: Multiple Choice Chapter 18: Implementing Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 477

6. A hospitalized client has become constipated in recent days, in spite of maintaining a high fluid intake and taking oral stool softeners. The client reports feeling mortified to attempt a bowel movement on a commode at the bedside, where staff and other clients can hear. The nurse should respond by modifying which resource? A. Environment B. Personnel C. Equipment D. Client and visitors

A Rationale: Providing an environment for the client that is more conducive to privacy and, ultimately, to elimination needs is necessary in this case. The equipment (i.e., the commode) is not the problem, but rather its proximity to others. The staff and the client are not central to the client's new problem. Question format: Multiple Choice Chapter 18: Implementing Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 483

2. A nurse recently attended a conference that focused on management of acute coronary syndrome. In preparing a plan of care for a client admitted with acute coronary syndrome, the nurse considers the information from the conference. Which resource is the nurse using to enhance practice? A. Evidence-based practice B. Clinical experience C. Current medical practice D. Ethical and legal guides to practice

A Rationale: Reading professional journals and attending continuing education workshops and conferences provide the nurse with research on updated care practices. In this question, the nurse is using learned evidence-based practice to guide the development of the plan of care. Nurses are responsible to learn current standards of care which dictate their nursing practice and know ethical and legal dimensions of practice when providing care. Nurses also base nursing care on clinical experience, which guides every day practice. Question format: Multiple Choice Chapter 18: Implementing Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 488

5. The nurse in a clinic located in a high-rise building on a university campus has noted that many clients who are supposed to receive care for HIV/AIDS have missed their appointments. When questioned, several of the clients stated to the nurse that the clinic is difficult to find and in an intimidating environment for a client experiencing homelessness. Which variable does the nurse identify as being inadequately addressed for these clients? A. psychosocial background and culture B. developmental stage of the clients C. ethical and legal guides to practice D. resources

A Rationale: Requiring clients to attend a clinic that is difficult to access and located in an environment that is intimidating shows a lack of consideration for the clients' psychosocial backgrounds and culture. Resources, development, and ethics are not central to this lapse in care. Question format: Multiple Choice Chapter 18: Implementing Cognitive Level: Understand Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 488

18. A nurse on duty finds that a client is anxious about the results of laboratory testing. Which intervention by the nurse reflects a supportive intervention? A. Sitting with the client to encourage the client to talk B. Telling the laboratory technician to speed up the results C. Calling the physician for an order for an anxiolytic D. Educating the client about reducing risk factors

A Rationale: Supportive interventions include recognizing the need for encouragement, unconditional acceptance of behaviors, and the positive effects of being present for clients during stress or crisis. To support the anxious client, the nurse should sit with the client and encourage the client to talk. Telling the laboratory technician to speed up the results and calling the physician for an order for anxiolytics are not supportive interventions but are acts of advocacy for the client. Educating the client about reducing risk factors is an educational intervention. Question format: Multiple Choice Chapter 18: Implementing Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 479

29. The nurse administers an insulin injection to a client with diabetes and informs the client what is being done, demonstrating each step of preparing and giving the injection. The nurse is promoting: A. client self-care. B. dependence of the client on the nurse. C. client competence. D. discipline of the client.

A Rationale: The plan of nursing care should include specific instructions for learning needs of the client to promote self-care and independence. Competency pertains to the nurse's ability (knowledge, skills, and attitudes) to provide safe and effective care. The nurse's role includes education, counseling, and advocating, but not providing discipline to clients. Question format: Multiple Choice Chapter 18: Implementing Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 480

22. The nurse is caring for a client with a diagnosis of end-stage renal disease. The client has expressed the desire to be "kept comfortable" and to not continue further treatment. The client's adult child arrives from out of town and is demanding to have further testing done to determine the best treatment option for the client. What is the best action for the nurse to take at this time? A. Explain to the adult child the wishes of the client. B. Arrange a meeting between the physician and the adult child. C. Contact the imaging center to schedule the testing. D. Persuade the client to agree to the adult child's request.

A Rationale: The priority is for the nurse to explain to the adult child the wishes of the client and support the client's decision. As an advocate, the nurse implements actions to protect the rights of the client. The other options do not support the client's decision. Question format: Multiple Choice Chapter 18: Implementing Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 485

34. The staff on the unit implements a specific set of evidence-based interventions for every client on the unit who has a central line inserted. These interventions include, but are not limited to, hand hygiene, barrier precautions for insertion, and skin antisepsis. Each member of the staff is involved and follows the steps meticulously every day until the central line is removed. The staff is carrying out which type of intervention? A. care bundle B. protocol C. standing order D. indirect care intervention

A Rationale: The staff is using a care bundle: a structured way of improving processes of care and client outcomes. A care bundle includes a small, straightforward set of evidence-based practices (generally 3 to 5) that, when performed collectively and reliably, have been proven to improve client outcomes. The power of a bundle "comes from the body of science behind it and the method of execution, with complete consistency. A bundle ties the practices together into a package of interventions that people know must be followed for every client, every single time." Protocols are written plans that detail the nursing activities to be executed in specific situations. Although some protocols specify routine aspects of nursing care (e.g., protocols that describe nursing responsibilities when a client is admitted to or discharged from the institution), other protocols include standing orders that empower the nurse to initiate actions that ordinarily require the order or supervision of a health care provider. An indirect care intervention is a treatment performed away from the client but on behalf of a client or group of clients. Indirect care interventions include nursing actions aimed at management of the client care environment and interdisciplinary collaboration. Question format: Multiple Choice Chapter 18: Implementing Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 480

25. The nurse is delegating a task to the assistive personnel (AP). What is the best instruction by the nurse? A. "Notify me right away if the client's systolic blood pressure is 170 or greater." B. "Let me know if the client's blood pressure becomes elevated." C. "If the client's blood pressure falls outside normal limits, come get me." D. "I need to know if the client's blood pressure changes from the normal baseline."

A Rationale: When delegating tasks, it is essential for the nurse to give clear instructions to the person to whom the task is being delegated. The statement that includes specific parameters for the systolic blood pressure clearly identifies what the AP should be alerted to and the subsequent action to take. The other three options are vague and do not provide adequate direction for the AP. Question format: Multiple Choice Chapter 18: Implementing Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 490

33. The client states to the nurse, "I do not know what they are doing for me. I see so many doctors. One says one thing, another says something else." What are appropriate action(s) by the nurse to assist the client in understanding the plan of care? Select all that apply. A. Make rounds with health care professionals when visiting the client. B. Restate recommendations in simple terms that the client will understand. C. Read the consultation and progress notes written by health care professionals. D. Explain the plan of care to the client's family who can then discuss it with the client. E. Assist the client to identify and write questions for the health care professionals.

A, B, C, E Rationale: To assist the client who does not understand the plan of care, the nurse would make rounds with other health care professionals and read the consultation and progress notes of the health care professionals. The nurse is able to stay informed of the medical plan of care. The nurse would then be able to restate the medical plan of care in simple terms for the client. The nurse would assist the client to identify and write questions that the client could ask the health care professionals to obtain further information. This action helps the client be empowered and stay informed. It would not be appropriate to explain the plan of care to the client's family before it is discussed with the client and without the client's consent. This would be a violation of the client's privacy. Question format: Multiple Select Chapter 18: Implementing Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Caring Reference: p. 477

21. Which client statement(s) identifies a potential factor interfering with following the plan of care? Select all that apply. A. "I do not drive, so I was unable to fill my prescription." B. "I consult the list of low-sodium foods when preparing meals." C. "My social security check does not come until next week." D. "I dropped the strips for my fingerstick blood glucose testing in the bath water." E. "My adult child helps me with my range-of-motion exercises every morning and afternoon."

A, C, D Rationale: Common factors that contribute to a client not following the plan of care include inability to afford treatment (social security check) and limited access to treatment (does not drive, damaged testing strips). The client's adult child assisting with range-of-motion exercises and the client consulting a list of low-sodium foods reflect cognitive achievement of learning. Question format: Multiple Select Chapter 18: Implementing Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 490

31. The client has diabetes and an elevated blood glucose level. During the nursing assessment, the client states, "I can't afford the pill used to control my blood sugar." What are appropriate actions by the nurse for this client? Select all that apply. A. Make a referral to the social worker to find what financial assistance is available for the client. B. Tell the client, "You have to set priorities, and taking this medication is a financial priority." C. Consult with the primary care provider about prescribing a medication that is free at some stores. D. Document the client statement in the assessment record and take no further action. E. Write a new nursing diagnosis "Noncompliance related to inability to afford treatment."

A, C, E Rationale: When the client does not adhere to the plan of care, the nurse would reassess the client to determine the reason. In this case, the reason is inability to afford treatment. The nurse revises the plan and includes a new diagnosis relating to noncompliance. The nurse would include appropriate interventions such as refer to the social worker about financial assistance and to consult with the primary care provider about a medication that may be free. The statement about setting priorities is nontherapeutic. Taking no further action after documentation delays or omits effective treatment. Question format: Multiple Select Chapter 18: Implementing Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 490

12. A nurse is preparing to insert an intravenous line and begin administering intravenous fluids. The client has visitors in the room. What should the nurse do? A. Ask the visitors to leave the room. B. Ask the client whether visitors should remain in the room. C. Tell the client to ask the visitors to leave the room. D. Wait until the visitors leave to begin the procedure.

B Rationale: If visitors are in the client's room, check with the client to see whether the client wants the visitors to stay during the procedure. Asking the clients to leave the room or telling the client to have the visitors leave may be perceived as the nurse controlling the environment. Waiting until the visitors leave to begin the procedure may delay treatment and increase length of stay. Question format: Multiple Choice Chapter 18: Implementing Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 483

8. The researchers developing classifications for interventions are also committed to developing a classification of: A. diagnoses. B. outcomes. C. goals. D. data clusters.

B Rationale: The researchers involved in the development of Nursing Intervention Classification (NIC) are also committed to developing a classification of client outcomes for nursing interventions, to be called Nursing Outcomes Classifications (NOCs). This research aims to identify, label, validate, and classify nursing-sensitive client outcomes and indicators, evaluate the validity and usefulness of the classification in clinical field-testing, and define and test measurement procedures for the outcomes and indicators. Nursing diagnoses are used after assessment to identify the plan of care. Goals are developed after the diagnosis for endpoints of care. Goals are more global than specific. Data clusters are information related to a specific area such as respiratory clusters (which include lung assessment, respiratory rate, and pulse oximetry). Question format: Multiple Choice Chapter 18: Implementing Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 475

20. Which statements accurately describe a recommended guideline for implementation? Select all that apply. A. When implementing nursing care, remember to act independently, regardless of the wishes of the client or family. B. Before implementing any nursing action, reassess the client to determine whether the action is still needed. C. Assume that the nursing intervention selected is the best of all possible alternatives. D. Consult nursing colleagues and related literature to see whether other approaches might be more successful. E. Reduce one's repertoire of skilled nursing interventions to ensure a greater likelihood of success.

B, D Rationale: When implementing nursing care, the nurse should act in partnership with the client and family and reassess the client to determine whether the nursing action is still needed. The nurse should always question whether the nursing intervention selected is the best of all possible alternatives. The nurse should consult colleagues and related nursing literature to see whether other approaches might be more successful. The nurse should develop a repertoire of skilled nursing interventions and check to make sure that the ones selected are consistent with standards of care and within legal and ethical guidelines to practice. Question format: Multiple Select Chapter 18: Implementing Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 487

9. What activity is carried out during the implementing step of the nursing process? A. Assessments are made to identify human responses to health problems. B. Mutual goals are established and desired client outcomes are determined. C. Planned nursing actions (interventions) are carried out. D. Desired outcomes are evaluated and, if necessary, the plan is modified.

C Rationale: During the implementing step of the nursing process, nursing actions (interventions) formulated during the planning step are carried out. Assessments are made to identify human responses to health problems, these are completed in the assessment phase. Mutual goals are established and desired client outcomes are determined during the diagnosis phase. Desired outcomes are evaluated and, if necessary, the plan is modified in the evaluation phase. Question format: Multiple Choice Chapter 18: Implementing Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 475

23. Which action is a responsibility of the nurse in the nurse-client-family team relationship? A. Provide creative leadership to make the nursing unit a satisfying and challenging place to work. B. Support the nursing care given by other nursing and non-nursing personnel. C. Educate the family to be informed and assertive consumers of health care. D. Coordinate the inputs of the multidisciplinary team into a comprehensive plan of care.

C Rationale: Educating the family to be informed and assertive consumers of health care is a role responsibility in the nurse-client-family relationship. Responsibilities of the nurse in the nurse-health care team relationship include coordinating the inputs of the multidisciplinary team into a comprehensive plan of care. In the nurse-nurse relationship, the nurse provides creative leadership to make the nursing unit a satisfying and challenging place to work, and supports the nursing care given by other nursing personnel. Question format: Multiple Choice Chapter 18: Implementing Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 479

14. The nursing staff on one team in a long-term care facility often plays loud rock music on the radio for residents to listen to in the common areas. The staff also organizes children's games as a form of physical and recreational therapy. What is the staff doing in these situations? A. The staff is considering the hearing level of older adults by playing loud music. B. The staff is failing to consider visual deficits that occur when a person ages. C. The staff is ignoring the developmental needs of the older adults in the facility. D. The staff is meeting the clients' needs for sensory input.

C Rationale: Nurses must be careful not to let stereotypes about developmental stages and tasks influence client care. Playing loud rock music and designing children's games are not appropriate for this age group. Older people have challenges with age-related changes to vision and hearing. These activities ignore the older adults' probable needs and is demeaning. Question format: Multiple Choice Chapter 18: Implementing Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 487

10. A nurse is changing a sterile pressure injury dressing based on an established protocol. What does this mean? A. The nurse is using critical thinking to implement the dressing change. B. The client has specified how the dressing should be changed. C. Written plans are developed that specify nursing activities for this skill. D. The physician verbally requested specific steps of the dressing change.

C Rationale: Protocols (written plans that detail the nursing activities to be executed in specific situations) are nurse-initiated interventions. They expand the scope of nursing practice in certain clearly defined situations. The client is usually not involved in the decision of how nursing care is provided in a protocol. The physician may consult on the development of the nursing protocol. A physician if requesting specific steps in the dressing change would not verbally request them but enter the steps in the orders for the client. Critical thinking is used in nursing care but not in established protocols. Question format: Multiple Choice Chapter 18: Implementing Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 480

26. Which action would be inappropriate for the nurse to perform when implementing a client's plan of care? A. Ask the client, who speaks the dominant language as a second language, to state in one's own words what it means to be NPO. B. Seek input from the family on how the client with aphasia normally communicates at home. C. Respond to the postoperative client's question by stating that baths are given only in the morning. D. Request that family members provide ethnic or cultural foods of the client's liking.

C Rationale: The nurse implements care that is culturally sensitive and individualized for the client. The nurse forms a partnership with the client and family when implementing care. The response by the nurse indicating a set time for baths is not reflective of being open to individualizing client care. The other options are consistent with the guidelines for implementing. Question format: Multiple Choice Chapter 18: Implementing Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 487

24. The nurse is caring for a client with a diagnosis of colon disease. The client has expressed to various members of the health care team the desire to be "kept comfortable" and to not continue further treatment. The client asks the nurse to be present when the client discusses the decision with other family members. In which professional nursing relationship is the nurse participating? A. Nurse-client B. Nurse-nurse C. Nurse-client-family D. Nurse-health care team

C Rationale: The nurse is fulfilling role responsibilities of the nurse-client-family relationship when being present for a discussion of the matter by the client and family. The nurse-client relationship does not need the family involvement. Nurse-nurse relationship occurs when the nurses are discussing client care or handoff communication. Nurse-health care team occurs with discharge planning or during ethical conferences where all members involved in the care assist with discussing the client's care. Question format: Multiple Choice Chapter 18: Implementing Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 477

16. A nurse delegates a specific intervention to the unlicensed assistive personnel (UAP). What implications does this have for the nurse? A. The UAP is responsible and accountable for their actions. B. Nurses do not have authority to delegate interventions. C. The nurse transfers responsibility but is accountable for the outcome. D. The UAP can function in an independent role for all interventions.

C Rationale: Unlicensed assistive personnel (UAPs) are trained to function in an assistive role to the registered nurse (RN) in client activities as delegated and supervised by the RN. Delegation is the transfer of responsibility of an activity to another individual while retaining accountability for the outcome. Nurses can delegate tasks to the UAP, but the UAP cannot function independently. Accountability for the action lies with the nurse. Question format: Multiple Choice Chapter 18: Implementing Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 490

19. Which nursing actions(s) is important when delegating to the unlicensed assistive personnel (UAP)? Select all that apply. A. ensuring that the UAP closely follows the nursing process while providing care B. auditing the client documentation that the UAP records after performing interventions C. taking frequent mini-reports from the UAP to ensure that changes in client status are identified D. informing the UAP of which clinical cues to be alert for and why E. making frequent walking rounds to reassess the clients for which the UAP is caring

C, D, E Rationale: The Five Rights of Delegation are right task, right circumstance, right person, right directions and communication, and right supervision and evaluation. Following these rights, the nurse must take careful action to ensure that delegation results in safe and competent client care. This necessitates such measures as taking frequent mini-reports, identifying the clinical cues that the unlicensed assistive personnel (UAP) should be aware of, and performing rounds often. The UAP is not normally educated to follow the nursing process or to perform documentation. Question format: Multiple Select Chapter 18: Implementing Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 491

27. Nursing students need to learn to care for themselves in order to prepare to be professional nurses. Which activities would fail to prepare nursing students for the delivery of client care? A. Time management, communication, and establishing a support system B. Establishing a support system, a sense of humor, and self-awareness C. Self-awareness, preparation for crisis, and stress management D. A sense of humor, anticipation of loss, and developing negative body image

D Rationale: Activities that would prepare nursing students for the delivery of client care include time management, communication, establishing a support system, self-awareness, stress management, a sense of humor, and preparation for crisis and loss. Negative body image of a nursing student is not desired as this can impact care to the clients. Question format: Multiple Choice Chapter 18: Implementing Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 493

17. Which characteristic most enables the nurse to be a role model for clients? A. Sense of humor B. Writing ability C. Organizational skills D. Good personal health

D Rationale: Good personal health enables nurses not only to practice more efficiently but also to be a health model for clients and their families. Nurses can help clients to imitate good health behaviors and eventually integrate them into their daily lives through the process of identification. A sense of humor is helpful for interpersonal skills and assisting a client to be comfortable. Writing and organizational skills are necessary for nursing documentation skills. Question format: Multiple Choice Chapter 18: Implementing Cognitive Level: Remember Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 493

15. A nurse administers a medication for pain but forgets to document it in the client's health care record. Legally, what does this mean? A. Nothing, the nurse's honesty will not be questioned. B. The nurse can add the documentation after the client goes home. C. The physician will verify that the nurse carried out the order. D. In the eyes of the law, if it is not documented, it was not done.

D Rationale: Nurses must carefully document each intervention. The legal truth is if it wasn't documented, it wasn't done. The physician cannot verify the nurse's action. If the medication causes an adverse effect, then the nurse's action will be held accountable. The nurse is not to add entries into the health record after the client has been treated and released. Question format: Multiple Choice Chapter 18: Implementing Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 490

11. A client who was previously awake and alert suddenly becomes unconscious. The nursing plan of care includes an order to increase oral intake. Why would the nurse review the plan of care? A. To implement evidence-based practice B. To ensure the order follows hospital policy C. To be sure interventions are individualized D. To be sure the intervention is safe

D Rationale: Nurses reassess the client and review the plan of care before initiating any nursing intervention. This is done to make sure that the plan of care is still responsive to the client's needs and is safe for the particular client. In this case, the nurse would not give oral fluids to an unconscious client. Nursing interventions should implement evidence-based practice, follow hospital policy, and be individualized. Question format: Multiple Choice Chapter 18: Implementing Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 480

28. The charge nurse overhears two nurses talking about nursing interventions. Which statement by one of the nurses indicates that further education is required? A. "Nursing interventions must be consistent with standards of care and research findings." B. "Nursing interventions must be culturally sensitive and individualized for the client." C. "Nursing interventions must be compatible with other therapies planned for the client." D. "Nursing interventions must be approved by other members of the health care team."

D Rationale: Nursing interventions should be based on the etiology in the nursing diagnosis, be compatible with other planned therapies, be consistent with standards of care and research, and individualized for the client. Nursing interventions can be independent, dependent, and interdependent. Independent nursing interventions are nurse-initiated interventions directed at the etiology of the client problem, they do not require approval from other members of the health care team, as the nursing plan of care is nurse-driven. Question format: Multiple Choice Chapter 18: Implementing Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 480

30. What role of the nurse is crucial to the prevention of fragmentation of care? A. Advocate B. Educator C. Counselor D. Coordinator

D Rationale: One of nursing's major contributions to the health care team is the role of coordinator. Care can easily become fragmented when clients are seen by numerous specialists—each interested in a different aspect of the client. It is important for the nurse to make rounds with other health care professionals and to read the results of consultations that clients have had with specialists. They can then interpret the specialists' findings for clients and family members, prepare clients to participate in the plan of care before and after discharge, and serve as a liaison among the members of the health care team. A nurse educator teaches the client about medications and hospitalization. A nurse advocate supports decisions or desires by the client. A nurse counselor actively listens and provides guidance with a client. Question format: Multiple Choice Chapter 18: Implementing Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 477

13. A new nurse is ambulating a client for the first time after surgery. What should the nurse do to anticipate and help prevent an unexpected outcome? A. Take the client's vital signs after ambulation. B. Ask the client's spouse to assist with ambulation. C. Delay ambulation until the following shift. D. Ask another nurse to help with ambulation.

D Rationale: Unexpected outcomes do occur, such as the fall of a postoperative client who is ambulated for the first time. In anticipation, the nurse could ask another nurse to help ambulate the client, thus decreasing this risk. Taking the client's vital signs will not prevent a fall. Neither asking the spouse to assist nor waiting until the next shift to ambulate the client is an appropriate intervention, as the former could cause a fall and the latter could delay care, which may cause a longer hospitalization. Question format: Multiple Choice Chapter 18: Implementing Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 483