209 Prep U Chapter 14

A nurse case manager is explaining the role of a case manager to a group of nursing students. One student asks if the case manager misses providing client care. What is the case manager's best response?

"I provide indirect care to my clients by coordinating their treatment with other disciplines." Explanation: Nurses can provide direct, indirect, and collaborative care for their clients. A case manager directs interventions on behalf of the client away from the client's bedside. The most appropriate response is "I provide indirect care...". The case manager's response about the work being important does not adequately explain the role of the case manager. The case manager's role in facilitating financial reimbursement is critical, but does not address the nurse manager's role in client care. The case manager is still providing client care.

An 84-year-old male has been admitted to the hospital several times in the past few months for exacerbations of chronic obstructive pulmonary disease (COPD) and elevated blood glucose. Which statement by the client could help identify the most likely reason for the changes in his health status?

"My wife's been gone for about seven months now." Explanation: The client's loss may be affecting how he is able to provide self-care. Emotionally, he may be depressed and questioning the benefits of his health care regimen, or he may have depended on his wife to help with his health care and not have the ability to take care of himself. Assessment of the client allows the nurse to alter the plan of care to meet his needs. The statements concerning having a family member staying with him, having help with the yard work and sorting medications into an organizer should be explored, but do not reflect the same emotional impact in the client's life as the loss of a spouse.

A client requires a change and reapplication of a colostomy bag. The nurse has never changed an ostomy bag before. What is the nurse's best course of action?

Ask a skilled nurse to assist with the procedure. Explanation: Professional nurses should only undertake tasks that they have been properly trained to perform. Since the nurse has no experience in changing an ostomy bag, it would be most appropriate to have the assistance of an experienced nurse. It would be inappropriate to ask the client how the bag is changed. The client is relying on the nurse to have the necessary technical knowledge. Reading the policy and procedure manual alone would not ensure the successful completion of the procedure. The necessity of the ostomy bag change has already been established.

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 client to verbalize the medication regimen and diet modifications required. Explanation: If the nurse suspects a client does not understand instructions, the first step is to assess the client's understanding. The most effective way to do that is to have the client repeat the client's understanding of the instructions. The other steps might be interventions that the nurse would institute after determining the client's needs.

The nurse 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. Explanation: After a nurse has performed an intervention, the next step is to evaluate the effectiveness of the intervention. The nurse should assess the client's response to the ambulation. Informing the client when ambulation is scheduled next, discussing the client's feelings, and documenting the ambulation are important, but not until after the client has been reassessed.

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. Explanation: The nurse must take into consideration the client's developmental level and willingness to participate in care in order to successfully implement the plan of care. The client is a teenager and socialization with a peer group is essential, so the nurse would most appropriately wait until the visitors left. Telling the visitors to leave in 10 minutes might upset the client and hinder the education. Simply asking if the client has questions does not appropriately educate the client. Leaving written information does not ensure that the client will read or understand the information.

A nurse documents the following diagnosis for a hospitalized client: "Risk for Imbalanced Nutrition: More Than Body Requirements." What is the major goal of interventions for a risk diagnosis?

Prevent the problem Explanation: For "risk" nursing diagnoses, the priority goal is to prevent the problem from occurring by implementing interventions that reduce or eliminate risk factors or by collecting additional data. Promoting higher-level wellness is a goal for "actual" nursing diagnoses.

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?

Reassess the appropriateness of the method of instruction. Explanation: It is the nurse's responsibility to revise the plan of care if an intervention is not successful. The most appropriate action of the nurse would be to determine if the initial education was the most effective for this client. Simply teaching the content again without reassessing the client's needs would not necessarily be effective. A support group might be helpful, but not until the client's needs are evaluated. The case manager is not responsible for the client's learning.

The nurse caring for a client who is recovering after a motor vehicle accident is planning for the client to begin increasing responsibility for self-care. What would be the nurse's most appropriate strategy?

The nurse encourages the client to take a shower instead of receiving a bed bath. Explanation: It is important for the nurse to encourage the client to achieve independence in self-care. The nurse would best accomplish this by encouraging the client to gradually do more for himself. There is no evidence that the client's recovery is progressing too slowly. There is no indication that an early discharge would be beneficial for the client. There is also no indication that the family is doing too much for the client. The client is not fully capable of self-care and will still need the assistance of family.

When the nurse enters the room to assess a client's vital signs, the client insists that the nurse perform hand washing. What is the nurse's most appropriate action?

When the nurse enters the room to assess a client's vital signs, the client insists that the nurse perform hand washing. What is the nurse's most appropriate action?

The student nurse is preparing to ambulate an obese client. The RN is concerned about the student's ability to safely ambulate the client. What would be the nurse's most appropriate action?

ell the student that the RN will assist the student with the client's ambulation. Explanation: The client's safety is always the nurse's primary concern. If the nurse feels there is a possibility for injury to the client, one strategy to prevent it is to offer assistance. By the nurse assisting the student, client safety is assured while still allowing the student to learn. Having the nursing assistant ambulate the client or instructing the student not to ambulate the client does not assist the student's learning. Asking the client if the client feels comfortable is inappropriate.

A student nurse received a report on his assigned clients for the clinical day. Which of the following clients should the student nurse plan to assess first?

An asthma client who reports shortness of breath with a respiratory rate of 26 bpm Explanation: According to the ABC priority framework, the client who should be assessed first is the asthma client with shortness of breath and a respiratory rate of 26 bpm. The appendectomy client with an elevated temperature should be assessed for suspected infection. However, this is not the priority action. The diabetic client should receive teaching regarding administration of insulin but this is not a priority. The hysterectomy client should be assessed for possible hemorrhage. However, according to the ABC priority framework, this is not the priority.

The surgeon is insisting that a client consent to a hysterectomy. The client says that she will not make a decision without her husband's consent. What is the nurse's best course of action?

Ask the surgeon to wait until the client has had a chance to talk to her husband. Explanation: It is important to consider the client's wishes, so the nurse should advocate for the client and ask the surgeon to wait until the client has talked to her husband. Telling the client that she is responsible for her health care decisions does not respect the client's desire to consult her husband. The client has not indicated that there she is fearful of her husband. Informing the surgeon that the nurse will not sign the consent form will not satisfy the client's request

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

Ask the surgeon to wait until the client has had a chance to talk to her husband. Explanation: It is important to consider the client's wishes, so the nurse should advocate for the client and ask the surgeon to wait until the client has talked to her husband. Telling the client that she is responsible for her health care decisions does not respect the client's desire to consult her husband. The client has not indicated that there she is fearful of her husband. Informing the surgeon that the nurse will not sign the consent form will not satisfy the client's request.

As part of the plan of care, a nurse administers scheduled pain medication to a post-operative client with a pain level of 6 on a 0 to 10 scale. Which action best represents the next step in the nursing process?

Assess pain level in 30 minutes. Explanation: Since administering a pain medication is implementing the plan of care, the next step would be to reassess the client's pain level. By reassessing the client's pain, the nurse knows if the current plan of care is safe and effective for the client, or if changes need to be made to meet the client's needs. Assessing the respiratory rate is an appropriate intervention, but 40 minutes is much too long to wait. The nurse must first assess the patient's pain level before ambulating the patient. Giving a prn dose of analgesic for breakthrough pain first requires assessment of the pain level.

The mother of a pediatric client being discharged confides to the nurse that her husband is abusive and she is afraid to return home. What is the nurse's most appropriate action?

Coordinate with the case manager to make a safe discharge plan. Explanation: The nurse's top priority is the safety of the client. The person most qualified to consider the options available to protect the mother and client is the case manager. It is not sufficient to simply give the mother telephone numbers of women's shelters. This does not take into account the possible needs of the child after discharge. Advising the mother that she should report concerns to the police does not address the discharge needs of the client. Arranging a counseling session does not meet the immediate discharge needs of the client.

Which of the following is a nursing intervention that facilitates life span care?

Educate family members about normal growth and development patterns. Explanation: Knowledge of normal growth and development is essential for family members to promote their own health and welfare throughout the life span, and to facilitate family functioning. Childbearing care includes interventions to assist in understanding and coping with psychological and physiological changes during the childbearing period. Coping assistance includes interventions to assist the client in building on his or her strengths, to adapt to a change in function, or to achieve a higher level of function. Risk management includes interventions to initiate risk reduction activities.

Nurses perform many independent nursing actions when caring for patients. Which action is considered an independent (nurse-initiated) action?

Helping to allay a patient's fears about surgery Explanation: An independent (nurse-initiated) action is one that is not dependent on the physician. Helping the patient with decreasing their fear about surgery by answering questions or arranging a meeting with the surgeon is an independent nursing intervention. Executing physician's orders, such as catheterization and medication administration, are examples of dependent nursing interventions. Meeting with other health care professionals describes collaborative care.

As the nurse bathes a patient, she notes his skin color and integrity, his ability to respond to simple directions, and his muscle tone. Which statement best explains why such continuing data collection is so important?

It enables the nurse to revise the care plan appropriately. Explanation: Continuous data collection ensures that the nurse has the most current patient data to evaluate, which allows for updating the care plan as needed. A complete assessment is performed upon admission, but the patient's condition is always changing. The purpose of continued data collection is to provide good patient care; it does not related directly to efficiency of nursing care. While continuous data collection meets standards of care, it is not the primary reason for ongoing assessments.

The nurse ascertains that a client is failing to follow the plan of care that was collaboratively developed. Further investigation determines that the plan of care is not appropriate for this client. What is the nurse's next step in correcting this problem?

Making changes in the plan of care based upon assessment data Explanation: A plan of care that is inappropriate for the client requires a change in the plan of care, not a change in the client. In situations when the plan of care is appropriate, the nurse must evaluate factors that contribute to the client's failure to comply. Such factors include lack of family support, lack of understanding of the benefits of compliance, low value attached to the outcomes and related interventions, and adverse or emotional effects of treatment.

The physician has ordered that the client should ambulate three times a day. The nurse enters the room to ambulate the client and the client complains of pain. What is the nurse's most appropriate action?

Medicate the client and wait to ambulate later. Explanation: It is most appropriate to manage the client's pain first. The client will be able to ambulate more easily and it is not necessary to cause the client further pain. Ambulating first considers the needs of the nurse, not the client. The client has not indicated misunderstanding of benefits or the importance of ambulation.

The nurse is coordinating care for the client with continuous pulse oximetry who requires pharyngeal suctioning. Which staff member should the nurse avoid delegating the task of suctioning?

Nursing assistant who is a nursing student Explanation: The nurse should avoid delegating this client to the nursing assistant. Suctioning and the association evaluation of the client would be within the scope of practice of the registered nurse, licensed practical nurse, and the senior nursing student but not the nursing assistant.

The 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 Explanation: A sufficient number of nurses are needed to respond to the disaster. The department is not full of clients and sufficient supplies are available.

A client with hypertension being seen for follow-up care has a blood pressure of 160/100. The client reports following the treatment regimen closely and that blood pressure readings have been elevated for the last two weeks. What is the nurse's most appropriate action?

Report the findings to the physician for further plans. Explanation: The nurse should report the findings to the physician so that the treatment regimen can be revised. The client reports following the treatment regimen so reinforcing the instructions is not indicated. Interviewing the family would indicate to the client that the nurse did not trust the client's report, so this would be inappropriate. The nurse cannot tell the client that the blood pressure medication will have to be changed because that is the physician's decision.

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?

Reschedule the client's bath to the evening shift. Explanation: The client's preferences are a primary consideration in scheduling interventions. The client's preference to have a bath at night requires a change in scheduling. Asking for permission to give the bath in the morning does not address the client's preference. The schedule of the nurses should not take priority over client needs. Informing the client about sleep medication does not address the client's preference.

The nurse is discussing diabetes mellitus with the family members of a client recently diagnosed. In order to promote the health of the family members, what would be the most important information for the nurse to include?

Risk factors and prevention of diabetes mellitus Explanation: An important nursing function is to enable clients to prevent illness. Since a member of the family has developed diabetes, the other family members are also at risk. The nurse would most appropriately educate the family about the risk factors and prevention of diabetes mellitus. Knowledge of the medications used to treat diabetes is not necessary at this time and does not help meet the family's needs. The severity of the client's disease does not have an impact on the family's health. Knowledge of the cellular metabolism of glucose is not necessary for the family's health.

The nurse is caring for a client who does not speak the same language. The UAP (unlicensed assistive personnel) speaks the same language as the client. What parts of communicating with the client could the nurse appropriately delegate to the UAP? Mark all that apply.

• Ask the client questions regarding personal care needs. • Orient the client and family to the room, including the call light button. Explanation: Delegation to unlicensed assistive personnel requires knowledge of the RN role and what tasks can be legally delegated to the UAP. The RN can delegate asking clients questions about personal care needs and orientation to the room (for example, the call light button). It is inappropriate to have the UAP interview the client as part of the admission assessment, or provide teaching to the client, or provide teaching to the family, or counsel the client. Those duties are legally the role of the RN and would be most appropriately addressed with a professional translator interpreting for the nurse and the client.

The nurse is planning instruction on wound care to an adult client. What variables would cause the nurse to alter the teaching plan? Mark all that apply.

• The client denies the need for teaching. • The client is blind. Explanation: The client's blindness will require the nurse to alter the teaching plan to fit the client's needs. The teaching might also require teaching another person to perform the wound care. If the client denies the need for teaching, attempting to teach the client at this time will be ineffective. The nurse will need to determine why the client denies the need for teaching and address that issue first. The facts that the client is male, married, and an architect do not have any bearing on the instruction.