Chapter 18: Implementing
Which type of nursing intervention is oxygen administration and why is it considered to be so?
A dependent nursing intervention, because oxygen is considered a drug that requires a health care provider's order
A nurse is catheterizing a client. Which scenario demonstrates steps the nurse would take to ensure client respect and privacy?
Close the door to the room, explain the procedure to the client, and cover all areas of the client, only exposing the area for catheterization.
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 possible alternatives to a blood transfusion with the health care provider.
The nurse is preparing a client for surgery when the client tells the nurse that the client no longer wants to have the surgery. How should the nurse most appropriately respond?
Discuss with the client the reasons for declining surgery.
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.
During morning report, the night nurse tells the oncoming nurse that the client has been medicated for pain and is resting comfortably. Thirty minutes later, the client calls and requests pain medication. What is the nurse's appropriate first action?
Go to the client and assess the client's pain
Which is an independent (nurse-initiated) action?
Helping to allay a client's fears about surgery
The emergency room nurse is performing an initial assessment of a new client who presents with severe dizziness. The client reports a medical history of hypertension, gout, and migraine headaches. Which step should the nurse take first in the comprehensive assessment?
Perform vital signs and blood glucose level.
When the nurse enters the room to assess a client's vital signs, the client insists that the nurse perform handwashing. What is the nurse's most appropriate action?
Praise the client for taking an active role in the client's care.
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?
Surveillance
Go to the client and assess the client's pain
To give the client the opportunity to actively participate in care
The nurse is preparing to administer a blood pressure medication to a client. To ensure the client's safety, what is the priority action for the nurse to take?
Assess the client's blood pressure to determine if the medication is indicated.
Discharge plans for a client with a mental health disorder include living with family members. The nurse learns that the family is no longer willing to allow the client to live with them. What is the nurse's most appropriate action?
Collaborate with other disciplines to revise the discharge plans.
After instituting interventions to increase oxygenation, the client shows no signs of improvement. What is the nurse's priority action?
Communicate with the health care provider for additional orders.
Which statement best explains why continuing data collection is important?
It enables the nurse to revise the care plan appropriately.
The nurse is caring for a client with congestive heart failure. The nurse manager informs the nurse that the client was enrolled in a clinical trial to assess whether a 10-minute walk, 3 times per day, leads to expedited discharge. Which type of evaluation best describes what the researchers are examining?
Outcome
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.
Before implementing any planned intervention, which action should the nurse take first?
Reassess the client to determine whether the action is needed.
A new unlicensed assistive personnel (UAP) is preparing to ambulate an obese client. The registered nurse (RN) is concerned about the UAP's ability to safely ambulate the client. Which would be the nurse's most appropriate action?
Tell the UAP that the RN will assist the UAP with the client's ambulation.
What assessment data would indicate to the nurse at the conclusion of an education session that the client education was effective? Select all that apply.
The client verbalizes understanding of the instructions. The client is able to answer the nurse's questions. The client discusses the specifics of what was taught during the session.
The nurse is discussing dietary options with a client who is disappointed due to not being able to have foods the client previously enjoyed. The nurse states, "You may not be able to have steak at this point, but you can have grilled salmon or grilled chicken. Which do you prefer?" What is the purpose for giving the client an option?
To give the client the opportunity to actively participate in care
When the nurse is administering medication, an older adult client states, "Why does everyone keep asking my name? I've been here for days." How should the nurse respond to the client?
We ask your name to ensure that we are treating the right client."
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?
unlicensed licensed personnel
A client is admitted to the mental health center after attempting suicide. Which client concern is the priority for the nurse to manage?
Risk of self-harm
The nurse has prepared to educate a client about caring for a new colostomy. When the nurse begins the instruction, the client states, "I am not ready to deal with this now. I am feeling overwhelmed." What is the nurse's most appropriate action?
Discontinue the education and attempt at another time.
Which is the nurse's priority question to consider prior to delegating a task to an unlicensed assistive personnel (UAP)?
Does this task fall within the scope of a UAP?
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?
Help the client achieve optimal levels of health
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.
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.
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?
unlicensed assistive personnel who is in nursing school
The nurse is caring for a client who does not speak the same language. The unlicensed assistive personnel (UAP) speaks the same language as the client. What parts of communicating with the client could the nurse appropriately delegate to the UAP? Select all that apply.
Ask the client questions regarding personal care needs. Orient the client and family to the room, including the call light button.
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.
The surgeon is insisting that a client consent to a hysterectomy. The client refuses to make a decision without the consent of the client's spouse. What is the nurse's best course of action?
Ask the surgeon to wait until the client has had a chance to talk to the spouse.
One hour after receiving pain medication, a postoperative client reports intense pain. What is the nurse's appropriate first action?
Assess the client to determine the cause of the pain.
The nurse is caring for a 10-year-old client who is newly diagnosed with a seizure disorder. What variable would alter the nurse's plan for educating the client and parent?
The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years.
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 restaurant 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?
Identify what barriers the client feels are preventing adherence with the plan.
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?
Make changes in the plan of care based upon assessment data.
The nurse is discussing diabetes mellitus with the family members of a client recently diagnosed. To promote the health of the family members, what would be the most important information for the nurse to include?
Risk factors for and prevention of diabetes mellitus
The client is having difficulty breathing. The respiratory rate is 44 and the oxygen saturation is 89% (0.89 L). The nurse raises the head of the bed and applies oxygen at 3 L/min per nasal cannula. How does the nurse determine the effectiveness of the interventions? Select all that apply.
The client's respiratory rate decreases. The client states, "I can breathe easier now." The client's oxygen saturation level increases.
A nurse who is experienced caring only for well babies is assigned to the neonatal intensive care unit (NICU) because of a shortage of nurses in the NICU. The nurse is assigned to an infant on a ventilator who will require blood transfusions during the shift. What is the nurse's most appropriate course of action?
The nurse should inform the charge nurse that the nurse does not have the experience to properly care for this client.
