Chapter 18: Implementing
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? Instruct the client to make alternate living arrangements. Inform the family that it is not possible to change the discharge plans. Collaborate with other disciplines to revise the discharge plans. Communicate with the health care provider about additional orders.
Collaborate with other disciplines to revise the discharge plans. Explanation: The discharge needs of this client are complicated, and the nurse will need the assistance of other disciplines to make a successful discharge plan. The client should have input into the future living arrangements, but the client does not have the resources to make the arrangements alone. The health care provider may be involved in the discharge plan, but additional orders are not necessary. It is not true (and would be inappropriate) to tell the family that discharge plans cannot be changed. If the family is unwilling to take the client, the placement will be unsuccessful.
The 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 health care providers wrote orders to ambulate the client, whereas another health care provider ordered strict bed rest for the client. How would the nurse most appropriately remedy this conflict? Collaborate with the physical therapist to determine the client's ability. Instruct the client to ask the health care providers for clarifications of instructions. Assess the client to determine whether the client is capable of ambulation. Communicate with the health care providers to coordinate their orders.
Communicate with the health care providers to coordinate their orders. Explanation: As coordinator of care, the nurse is responsible for ensuring the continuity of the treatment plan. If conflicts occur in the treatment plan, the nurse should first consult with the health care providers who have written the conflicting orders. The nurse may assess the client to determine whether the client is capable of ambulation, but this does not resolve the conflict or determine whether ambulation is in the client's best interest. It is not the client's responsibility to clarify nursing orders. Collaboration with the physical therapist could become part of the plan later, but the health care providers's orders have to be clarified first.
The nurse must give instructions before discharge to a 13-year-old in a sickle cell crisis. Three of the client's friends from school are visiting. In order to assure effective instruction, what should the nurse plan to do? Give the visitors instructions to leave in 10 minutes. Leave written information for the client to read later. Ask the client if the client has any questions. Delay the instruction until the visitors leave.
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 an adolescent and socialization with a peer group is essential, so the nurse would most appropriately wait until the visitors leave. 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.
Which action is a nursing intervention that facilitates lifespan care? Educate family members about normal growth and development patterns. Identify coping strategies for the family that have worked in the past. Teach contraceptive options for planned pregnancy. Explore factors that could motivate adolescent members of the family to engage in risky behaviors.
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 lifespan, and to facilitate family functioning. Childbearing care includes interventions to assist in understanding and coping with psychological and physiologic 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.
Before implementing any planned intervention, which action should the nurse take first? Have the required equipment ready for use. Record the planned intervention in the client's medical record. Ask the client whether this is a good time to do the intervention. Reassess the client to determine whether the action is needed.
Reassess the client to determine whether the action is needed. Explanation: Although being prepared with the necessary equipment and checking with the client to make sure that the client is physically and psychologically ready for the intervention are important, it is crucial to reassess the client to determine whether the action is still needed before implementing any nursing intervention. Recording the intervention occurs after the nurse has completed the intervention.
A client is admitted to the mental health center after attempting suicide. Which client concern is the priority for the nurse to manage? Lack of support Risk of self-harm Feelings of not belonging Low self-esteem
Risk of self-harm Explanation: Safety and security are the priority for the client, so the risk of self-harm is what the nurse must address first. Lack of support, low self-esteem, and feelings of not belonging, although still important to address, are not as critical as safety and security.
he 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? Inform the surgeon that the nurse will not sign the informed consent form. Ask the client whether the client is afraid that the spouse will be angry. Remind the client that the client is responsible for the client's own health care decisions. Ask the surgeon to wait until the client has had a chance to talk to the spouse.
Ask the surgeon to wait until the client has had a chance to talk to the spouse. 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 the spouse. Telling the client that the client is responsible for the client's own health care decisions does not respect the client's desire to consult the spouse. The client has not expressed being fearful of the spouse. Informing the surgeon that the nurse will not sign the consent form will not satisfy the client's request.
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? Instruct the client's family to assist the client to ambulate to the bathroom. Consult with the physical therapist to determine the client's ability. 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.
Revise the care plan to allow the client to ambulate to the bathroom independently. Explanation: The intervention of assisting the client to the bathroom is no longer indicated, so the nurse would appropriately revise the care plan to discontinue that intervention. A consult with a physical therapist is not necessary to verify the nurse's independent assessment. If the client is safe to ambulate to the restroom independently, it is not necessary for the family to assist.
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? Collaborative Supportive Surveillance Maintenance
Surveillance Explanation: Surveillance or monitoring nursing interventions include detecting changes from baseline data and recognizing abnormal responses. Nurses rely on the senses to detect changes, such as observing the appearance and characteristics of clients and hearing by auscultation, pitch, and tone. Nurses use these surveillance activities to determine the current status of clients and changes from previous states. Maintenance nursing interventions involve the nurse assisting the client with performing routine activities of daily living. Supportive nursing measures involve providing basic comfort and emotional care to the client. Collaborative nursing interventions involve coordination and communication with health care professionals in other fields to meet the client's needs.
Which is an independent (nurse-initiated) action?
Helping to allay a client's fears about surgery Explanation: An independent (nurse-initiated) action is one that a nurse may initiate and carry out independently, without an order from any other health care provider. Helping the client decrease fear about surgery by answering questions or arranging a meeting with the surgeon is an independent nursing intervention. Interventions that involve executing a health care provider's orders, such as for catheterization and medication administration, are dependent nursing interventions. Meeting with other health care professionals describes collaborative care.
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? Maintenance Surveillance Psychomotor Educational
Surveillance Explanation: Surveillance interventions include detecting changes from baseline data and recognizing abnormal response. Nurses rely on the senses to detect changes, such as observing the appearance and characteristics of clients and hearing by auscultation, pitch, and tone. Nurses use these surveillance activities to determine the current status of clients and changes from previous states. Educational interventions require instruction, demonstration, and return demonstration of knowledge or a skill set. Psychomotor interventions involve the nurse physically working with the client. Maintenance interventions involve the nurse assisting the client with performing routine activities of daily living.
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? You Selected:
unlicensed assistive personnel who is in nursing school Explanation: The nurse should avoid delegating this client to the unlicensed assistive personnel who is in nursing school. Suctioning and the associated evaluation of the client is within the scope of practice of the registered nurse, licensed practical/vocational nurse, and the senior student in nursing school who is present for clinical.
An 87-year-old client has been admitted to the hospital several times in the past few months for exacerbations of chronic obstructive pulmonary disease and elevated blood glucose levels. Which statement by the client could help identify the most likely reason for the changes in the client's health status? "I sort my medication into an organizer every week." "My daughter has been staying with me the past few weeks." "I asked my neighbors to help me with my yard work." "My wife's been gone for about 7 months now."
"My wife's been gone for about 7 months now." Explanation: The client's loss may be affecting how well the client is able to provide self-care. The client may be depressed and questioning the benefits of the health care regimen, or the client may have depended on the wife to help with health care and no longer has the ability to take care of himself. Assessment of the client allows the nurse to alter the plan of care to meet the client's needs. The statements concerning having a family member staying with the client, having help with the yard work, and sorting medications into an organizer all indicate factors that would improve the client's ability to provide self-care, not decrease it.
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? Determine the client's reaction to the medication in the past. Assess the client's blood pressure to determine if the medication is indicated. 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. Explanation: Before initiating any intervention, the nurse must determine if the intervention is still necessary. Before administering blood pressure medication, the blood pressure must be assessed. The client's reaction to the medication previously does not indicate if the medication is indicated at this time. The client's ability to verbalize the purpose of the medication is important to promote self-care, but it is not important for the client's safety at this time. The client's report of side effects would indicate an adverse reaction after the medication is administered, but it would not protect the client's safety before the medication is given.
With which nursing action is the nurse performing a surveillance or monitoring intervention? Administering a paracetamol tablet Auscultating bilateral lung sounds Applying therapeutic communication skills Providing assistance with hygiene
Auscultating bilateral lung sounds Explanation: Surveillance or monitoring nursing interventions include detecting changes from baseline data and recognizing abnormal responses. Nurses rely on the senses to detect changes: observing the appearance and characteristics of clients; hearing by auscultation, pitch, and tone; detecting odors and comparing them with past experience and knowledge of specific problems; and using touch to assess body temperature, skin condition, clamminess, or diaphoresis. Nurses use all of these surveillance or monitoring activities to determine the current status of clients and changes from previous states. Nurses often detect subtle changes in a client's condition and communicate them to the health care provider to minimize problems. Providing hygiene and administering a paracetamol tablet are examples of maintenance nursing interventions. Use of therapeutic communication skills is an example of a supportive nursing interventi
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 client's refusal with hospital risk managers. Discuss possible alternatives to a blood transfusion with the health care provider. Discuss the risks and benefits of a blood transfusion with the client. Discuss the client's options with other church members.
Discuss possible alternatives to a blood transfusion with the health care provider. Explanation: As coordinator of the client's care, the nurse functions as an intermediary between the health care provider and the client. In order to honor the client's wishes, the nurse would most appropriately consult with the health care provider to meet the client's physical needs, as well as the client's spiritual needs. The risk and benefits of a blood transfusion are not the relevant issue with the client. Discussing the client's options with other church members would violate the client's privacy and would not meet the client's physical needs. It might be advisable to discuss the client's refusal of care with the hospital risk manager to protect the legal requirements of the institution, but it is not the priority.
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. Teach the family to anticipate the client's needs to care for the client. Arrange with the nurse case manager for an early discharge. Perform all care activities for the client to facilitate rest.
Encourage the client to provide as much self-care as possible. Explanation: The nurse must encourage the client to provide as much self-care as possible in order to achieve the highest level of independence. Performing all care activities for the client makes the client dependent on the nurse. If the family anticipates and meets all the client's needs, this also hinders the client's recovery. An early discharge is not indicated because the client must be sufficiently recovered.
The nurse is proceeding through the nursing process in the care of a new client. During the implementation phase, the nurse will most likely accomplish what task? Implement the critical pathway for the client Identify a need for collaborative consults Establish trust and rapport with the client Help the client achieve optimal levels of health
Help the client achieve optimal levels of health Explanation: The purpose of the nursing implementation phase is to help the client achieve an optimal level of health. Implementing the critical pathway for the client is too narrow to represent the purpose of the implementation phase, although this may be the purpose of specific interventions that would be implemented during this phase. Identifying the need for collaborative consults is an action the nurse would perform in the planning phase of the nursing process. Establishing trust happens earlier in the nursing process.
Which action should the nurse take to ensure that an unlicensed assistive personnel (UAP) understands the instructions to perform a delegated task? Instruct the UAP to repeat the instructions to be sure the nurse has communicated clearly. Ask another UAP to observe and assist the UAP in performing the task. Request that the UAP place the steps of the task in the framework of the nursing process. Inform the UAP of the importance of following each step listed in the procedure manual.
Instruct the UAP to repeat the instructions to be sure the nurse has communicated clearly. Explanation: Instruct the UAP to repeat the nurse's instructions to be sure the nurse has communicated them clearly. The UAP must be clear on the difference between nursing tasks and the nursing process, as the nursing process structures care delivered by the registered nurse. Although it is important for the UAP to follow procedure manuals, it is important that the registered nurse is clear on the UAP's understanding of the steps through direct observation or discussions. It is not correct to ask another UAP to observe and assist the UAP in performing the task.
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? Revise the plan to include the inclusion of a support group. Report the client's inability to learn to the case manager. Teach the content again utilizing the same method. Reassess the appropriateness of the method of instruction.
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.
What are the advantages of using standard Nursing Interventions Classifications (NIC)? Select all that apply. Limiting the amount of reimbursement allowed for nursing services Allocating nursing resources Communicating nursing to non-nurses Teaching decision making Allowing the use of multiple systems of nomenclature Developing information systems
Teaching decision making Allocating nursing resources Developing information systems Communicating nursing to non-nurses Each of the interventions listed in the NIC has a label, a definition, a set of activities that a nurse performs to carry out the intervention, and a short list of background readings. This information encourages the teaching of decision making to new nurses and helps administrators plan more effectively for staff and equipment needs (nursing resources) and examine the effectiveness and cost of nursing care. The NIC also promotes communication of the nature of nursing to the public. The goal is not to limit but to encourage reimbursement for nursing services. The NIC allows for a standardized nomenclature rather than multiple systems of nomenclature.
The client reports right knee pain of 6/10 on the 10-point pain scale and requests medication. The nurse assesses and flushes the intravenous site before administering IV analgesia. Which type of intervention skill is the nurse using? Mechanical skill Interpersonal skill Intellectual skill Technical skill
Technical skill Explanation: Technical skills are used to carry out treatments and procedures, such as assessing and flushing an intravenous site. Nurses learn the specific skills through clinical practice. Intellectual skills include the ability to explain complex disease processes and treatment regimens to a client. Interpersonal skills, such as communication, allow the nurse to establish strong relationships and build trust with the client. Mechanical skills are not among the skills nurses need.
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 an architect. The client is blind. The client denies the need for education. The client is married.
The client is blind. The client denies the need for education. The client's blindness will require the nurse to alter the education plan to fit the client's needs. The education might also require teaching another person to perform the wound care. If the client denies the need for education, 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.
The registered nurse is working with an unlicensed assistive personnel. Which client should the nurse not delegate to the unlicensed assistive personnel? The client with continuous pulse oximetry who requires pharyngeal suctioning. The client who needs vital signs taken following infusion of packed red blood cells. The client who is pleasantly confused and requires assistance to the bathroom. The client who requires assistance dressing in preparation for discharge.
The client with continuous pulse oximetry who requires pharyngeal suctioning. Explanation: The nurse needs to perform the pharyngeal suctioning of the client with continuous pulse oximetry. This client requires the nurse to evaluate the client's response in pulse oximetry to the suctioning. The nurse can delegate the other clients to the unlicensed assistive personnel. Reference:
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 best response? Work with the evening shift to possibly reschedule. Tell the client that the health care provider has prescribed sleep medication if necessary. Ask the client for permission to give the bath in the morning. Inform the client the evening shift will not have time to give baths.
Work with the evening shift to possibly reschedule. 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 and the nurse should discuss the issue with the evening shift to determine if rescheduling is possible. 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 desires. Informing the client about sleep medication does not address the client's preference. To just brush off the client's desires is not showing holistic nursing care.
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. skills and assistance. logistics and planning.
equipment and personnel. Explanation: A key component of the organizing interventions is to ensure adequate equipment (extra supplies) and sufficient personnel to assist with more complex tasks. Skills are first learned in nursing school but then validated with policies and procedures of the institution. Assistance is necessary to assist with the skill but is not the main issue in this scenario. Environment would be related to the lighting and space. Client issues would be the correct response if the client was cognitively aware and not confused. Logistics and planning may be related to other issues such as making sure all the elements such as personnel, client, environment, and assistance are all present.
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 unlicensed licensed personnel senior student in nursing school who is present for clinical licensed practical/vocational nurse
unlicensed licensed personnel Explanation: The nurse should avoid delegating the dressing change to the unlicensed assistive personnel. The dressing change is within the scope of practice of the registered nurse, licensed practical/vocational nurse, and the senior student in nursing school.