Course Point - Chapter 14: Implementing

Which of the following nursing interventions is most likely to be allowed within the parameters of a protocol or standing order?

Administering a glycerin suppository to a constipated client who has not responded to oral stool softeners Standing orders and protocols often surround the management of bowel elimination. Modification of a client's IV fluid or administration of a new antihypertensive are client-specific interventions that are physician initiated. The care team cannot independently change a client's advance directive. (less)

The nursing is caring for several clients. Which client can the nurse delegate to the unlicensed assistive personnel?

Bathe a client with stable angina who has a continuous IV infusing. The nurse can delegate the client with stable angina who requires assistance with bathing to the unlicensed assistive personnel. The other clients require the clinical reasoning skills of the nurse to evaluate their response. (less)

The client reports right knee pain of 6/10 on the pain scale and requests for medication. The nurse assesses and flushes the IV site. Which type of intervention skill is the nurse using?

Mechanical skill Technical skills are used to carry out treatments and procedures. Nurses learn the specific skills through clinical practice. Technical competence means being able to use equipment, machines, and supplies in a particular specialty. (less)

The nurse is caring for Mr. H., a 35-year-old man who is hospitalized following a motorcycle accident. He has a traumatic brain injury. The nurse is working with Mr. H. on self-care behaviors. The following would help the nurse to assess the success of the nursing interventions except which of the following?

Model self-care behaviors for the client. This question asks specifically about evaluation. Modeling self-care behaviors is an intervention, not an evaluation or assessment technique. When considering the responses, first check for sentence structure. Only one of the choices contains the three elements of the nursing diagnosis: the diagnostic label, the related factors, and the defining characteristics. The question asks for an actual diagnosis; this eliminates any risk, wellness, or potential diagnoses. (less)

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. 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. (less)

A client admitted with a wound infection has a temperature of 102.1°F. The nurse administers ordered acetaminophen. How does the nurse plan to reassess the effectiveness of the medication?

Reassess the client's temperature in 1 hour. The nurse has administered the acetaminophen to decrease the client's temperature. To assess the effectiveness of the intervention, the nurse would reassess the client's temperature. The white blood cell count and wound exudate would give indications about the resolution of the infection, but not the effectiveness of the medication. The client's respiratory rate would not be affected. (less)

A nurse who is experienced caring only for well babies is assigned to the newborn intensive care nursery (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 she does not have the experience to properly care for this client. The nurse should recognize that she lacks the competence to safely care for a client with these complex needs and inform the charge nurse of the fact. This assignment would be an inappropriate delegation on the part of the charge nurse and could cause injury to the client. The other options do not take the safety of the client into consideration. (less)

A student nurse is performing a sterile dressing change on a client's abdominal incision. While establishing her sterile field, the nurse drops her forceps on the floor. She is unable to continue with the dressing change because she has no extra supplies in the room, and no one is present to bring new forceps. The student has failed to organize ...

equipment and personnel. A key component of the organizing interventions is to ensure adequate equipment (extra supplies) and sufficient personnel to assist with more complex tasks.

A nurse follows set guidelines for administering pain medication to clients in a critical care unit. This nurse's authority to initiate actions that normally require the order or supervision of a physician is termed:

standing orders. Standing orders empower the nurse to initiate actions that ordinarily require the order or supervision of a physician, such as pain medication administration based on specific criteria. Protocols are written plans that detail the nursing activities to be executed in specific situations; these include routine nursing care and standing orders. Nursing interventions refer to care administered by the nurse and can be dependent or independent in nature. Collaborative orders may include suggested care strategies from other health care personnel such as the physical therapist. (less)

Which are essential components for delegating nursing care? Select all that apply.

• The task is delegated to a person with sufficient knowledge and skill for completing the task. • Instructions have been clearly communicated by the nurse to the unlicensed assistive personnel. • The unlicensed assistive personnel can verbalize what information is to be reported to the nurse. Essential components of effective delegation include delegating the task to to a person with sufficient knowledge and skill for completing the task; communication of clear and specific instructions by the nurse to the unlicensed assistive personnel; and validation of understanding by the unlicensed assistive personnel regarding information to be reported to the nurse. The steps of the nursing process remain the responsibility of the nurse and are not delegated to unlicensed assistive personnel. (less)

The nurse is preparing to administer oxygen 3 liters/minute via nasal cannula. The nursing student asks, "What type of nursing intervention is oxygen administration?" What is the best response by the nurse?

"Oxygen administration is a dependent nursing intervention, as oxygen is considered a drug that requires a physician's order." Dependent nursing interventions, such as oxygen administration, require a physician's order. Independent nursing intervention are autonomous actions based on scientific rationale that a nurse executes to benefit the client in a predictable way related to the nursing diagnosis and expected outcomes. Nursing-initiated interventions, such as teaching, providing fluids, and assisting with guided imagery do not require a physician's order. (less)

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 primary reason for asking the client to state her name is to ensure that the nurse is dealing with the correct client. Asking the client to state her name is a habit that should be developed in nursing school, but that is not the reason nurses ask clients for their names. It is not just a hospital-specific policy to ask the client for her name, but it is a step that is used in all client care situations. Respecting clients' rights is important but that is not why nurses ask for their names. (less)

The client tells the nurse, "I think the nurse last night may have given me the wrong medication, but I was afraid to say anything." What is the nurse's most appropriate response?

"You should always speak up if you have any questions about your care." The priority is to empower the client into taking an active role in his care, so the nurse should tell the client to feel free to ask questions. The client does have the right to refuse, but this does not address the issue. Speaking to the nurse manager or the night nurse does not help the client deal with a similar situation in the future. (less)

The nurse is preparing a client with a bowel obstruction for emergency surgery. Of the following interventions, which has the highest priority?

Inform the client what to expect after the surgery. If the surgery is an emergency, the highest priority is to meet the client's immediate needs. The nurse should inform the client about what to expect after surgery. Discussing discharge plans, instruction in wound care, and dietary restrictions are important, but not necessary before the surgery. (less)

In the implementation step of the nursing process, a nurse is to utilize certain activities to be effective in the care of a client. Which activity is of highest priority?

Reassess client's needs. Competence in intellectual, interpersonal, and technical skills is required to carry out the implementation phase. Nurses can delegate parts of the plan of care to other members of the health care team, but the registered nurse (RN) maintains accountability for the supervision and evaluation of these people. Figure 15-1 illustrates the activities of implementation, which include the following: (a) reassess, (b) set priorities, (c) perform nursing interventions, (d) record nursing actions. (less)

Which nursing intervention is appropriate for a risk nursing diagnosis? Select all that apply.

• Prevent the problem. • Monitor the client's status. • Reduce or eliminate risk factors. Nursing interventions appropriate for risk nursing diagnoses include preventing the problem, reducing or eliminating risk factors, and monitoring the client's status. Promotion of higher-level wellness addresses actual nursing diagnoses, while collection of additional data to rule out the diagnosis would be necessary for possible nursing diagnoses. (less)

A client being treated for myasthenia gravis at home tells the nurse, "This medicine is so expensive. I have only been taking half of what the doctor ordered." How would the nurse most effectively meet this client's need?

Collaborate with other disciplines to determine the best way to meet the client's medication requirements. In order to meet the client's needs, it is most important to involve other disciplines in the client's care to utilize all available resources. Reinforcing the importance of the medication does not solve the financial problem. It may be necessary for the physician to prescribe a less expensive medication, but other options should be considered to address the holistic needs of the client. Some pharmaceutical companies have programs to help with medication expenses, but the client will need information in order to apply for the programs. (less)

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. 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. (less)

A nurse is preparing to educate a client about self-care after a cataract surgery. Which of the following would the nurse do first?

Determine the client's willingness to follow the regimen. The prerequisite to health education about self-care after cataract surgery is the client's willingness to follow the regimen. Once a nurse is aware of the client's readiness for learning, the nurse can implement outcome-based education plans. Identifying changes from baseline is important for monitoring interventions. Approval by the physician may not be necessary. Delegating the teaching activity to an unlicensed assistive personnel (UAP) is inappropriate because it is not in accordance with her capabilities. (less)

Which is a responsibility of the nurse in the nurse-nurse team relationship?

Provide creative leadership to make the nursing unit a challenging place to work. In the nurse-nurse relationship, the nurse provides creative leadership to make the nursing unit a satisfying and challenging place to work. Challenging the client to develop self-care abilities that promote health is a role responsibility in the nurse-client relationship. Intervening to promote healthy family functioning is a role responsibility in the nurse-client-family relationship. Responsibilities of the nurse in the nurse-healthcare team relationship include communicating nursing's perspective regarding the client and family. (less)

The nursing team, consisting of a nurse and experienced unlicensed assistive personnel, have worked well together for the past year. One of the nurse's assigned clients is injured in a fall and requires uninterrupted attention. The nurse instructs the UAP to feed a stable stroke client, assist with dressing a client in preparation for discharge, and take vital signs of a third client and notify the nurse if the client's blood pressure becomes low. Which error has the nurse made?

The nurse failed to communicate clear instructions regarding what constitutes a low blood pressure. The nurse failed to communicate clear instructions to the UAP. The delegated tasks are not too numersous and are within the scope of an UAP's role and responsibilities. The nurse has had ample opportunity to validate the UAP's knowledge and skill to perform the tasks, as they have worked together for the past year. (less)

Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?

bed bath for the newly-admitted client who has multiple skin lesions The safest delegation is to have the UAP bathe the client with skin lesions and report any abnormal findings to the nurse. Preparing insulin is outside of the UAPs scope of practice. The UAP may have the skills to insert an indwelling catheter and ambulate clients, but the clients involved each have qualifiers that complicate the tasks. (less)

The nurse is attending a conference on evidence-based practice. Which statement by the nurse indicates further education is needed?

"I must conduct research to validate the usefulness of my nursing interventions." Nursing interventions should be supported by a sound scientific rationale; however, nurses do not need to personally conduct research to establish the rationale for nursing interventions. Nurses can learn about evidence-based practice by reading professional nursing journals, attending nursing workshops, and consulting evidence-based practice resources, such as the Agency for Healthcare Research and Quality. (less)

The nurse is currently completing the last of three consecutive night shifts. The unit will be short-staffed on day shift and the charge nurse wants the nurse to work this as an overtime shift. What is the nurse's most appropriate response?

"I will not work tomorrow because I would be a danger to my clients." The nurse cannot care for client without first ensuring self-care. The nurse is tired and most appropriately is declining to work because the nurse will not be able to function at full capacity. Simply stating that the nurse wants a day off does not fully address the situation. The option of working tomorrow is not appropriate because the nurse needs to rest after working a night shift. (less)

A client with diabetes who has been closely following the prescribed plan of care for over a year is being seen at an outpatient setting. The client has not brought a log of daily glucose checks and tells the nurse, "I haven't been doing them regularly." What is the nurse's most therapeutic statement to the client?

"It seems like you are having difficulty with your care regimen." The nurse's open-ended statement acknowledging that the client is having difficulty with the care regimen encourages the client to discuss what has occurred that has caused the client to not manage the diabetes as was previously done. The statement reminding the client that health care is important will discourage the client to freely discuss any problems. A home health nurse or instructions given to the family may be indicated, but not until the client has verbalized the reasons that the care regimen has not been followed. (less)

The nurse is caring for a client admitted to the hospital for renal calculi. What is the best action to take first?

Assess for bladder distention. Urinary retention could occur if a kidney stone has become lodged in the urethra. Forcing fluids, straining the urine after each void, and diet as tolerated are appropriate interventions, but these do not address the safety issue of first assessing the bladder for distension; this could potentially cause the client discomfort and harm. (less)

The physician has ordered 100 mg of morphine sulfate IM to a client. The nurse knows that the usual dose is 10 mg of morphine sulfate. What is the nurse's most appropriate action?

Call the physician to clarify the order. To ensure the safety of the client, it is the nurse's responsibility to clarify any questionable orders. The best way to approach the situation is to discuss the order with the physician. Talking to the pharmacist may give the nurse further information, but will not change the physician's order. Giving the medication is not an option because the nurse feels that the dose is unsafe. Determining the previous dose does not address the order issued. (less)

A client in the last stages of pancreatic cancer tells the nurse, "I am tired of fighting. I am ready to die." What is the nurse's best action?

Collaborate with other disciplines to plan end-of-life care for the client. The client has indicated an acceptance of the terminal condition. To respect the client's wishes, the nurse should involve other disciplines, such as hospice care, in planning for the client's needs. The client has not asked the nurse for other treatment options, so researching other options is not honoring the client's wishes. Reminding the client to think "positive thoughts" dismisses the seriousness of the client's concerns. Speaking with a spiritual adviser might be part of the collaborative care, but it would not address all the client's needs. (less)

A client being treated with chemotherapy for breast cancer tells the nurse that she no longer wants to receive the medication because of the overwhelming nausea and vomiting. How should the nurse respond to the client's statement?

Consult with the physician to treat the client's nausea. The client has stated that the nausea and vomiting are causing her to want to discontinue the chemotherapy. The most appropriate action by the nurse is to confer with the physician to treat the client's discomfort. After the nausea and vomiting are gone, the client can decide if she wants to continue with the chemotherapy. Simply informing the physician that the client wants to discontinue the therapy is only giving part of the information. Reviewing the possible results of discontinuing the chemotherapy does not answer the client's concern. It is not appropriate to discuss the client's condition with the family without the client's consent. (less)

A staff nurse has asked the nursing student to perform an intervention that the nursing student has not been trained to perform? What is the appropriate approach for the nursing student to take?

Consult with your nursing instructor before performing the procedure. Whenever you are asked by a staff nurse to perform an intervention for which you lack training, you should consult with your instructor to see if you should attempt to perform it with supervision. Under no circumstances should you attempt to perform interventions beyond your capacity without supervision, even if instructed to do so by a staff nurse. Delegating the intervention to an unlicensed assistive personnel member is not an acceptable option, as you likely are not familiar with the training of this individual. (less)

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. The nurse should always perform client education when the client is receptive of the education. The client verbalizes not being ready to learn, so education should be discontinued and continued at another time. Asking for permission to teach a family member does not encourage the client to learn self-care and acquire independence. The client does not need medication for anxiety at this time. This is a normal reaction. It would not be productive to continue the education because the client is not ready to learn. (less)

A client has a nursing diagnosis of Possible Spiritual Distress. What is the most appropriate nursing intervention?

Discuss spirituality with the client. Interventions for a possible nursing diagnosis are directed at collecting more data to determine the appropriateness of the diagnosis. The only way to determine if the client is in spiritual distress is by discussing it with the client. The client's pastor does not know how the client feels. It would be inappropriate to offer to pray with the client if the client does not desire this. Leaving the client alone will not yield further information. (less)

The nurse is preparing a client for surgery when the client tells the nurse that he no longer wants to have the surgery. How should the nurse most appropriately respond?

Discuss with the client the reasons for declining surgery. The nurse needs further information before deciding what interventions are necessary, so the most appropriate action is to determine the client's reasons for refusal. Until the information is collected, the nurse cannot decide whether reviewing the risks and benefits of surgery would be effective. It is also premature to ask the client to discuss the decision with family members. It is not appropriate to notify the physician until the assessment is complete. (less)

A patient, who presented with high blood pressure, is put on a low-salt diet and instructed to quit smoking. The nurse finds him in the cafeteria eating a cheeseburger and French fries. He also tells you there is no way he can quit smoking. What is the nurse's first objective when implementing care for this patient?

Identify why the patient is not following the therapy. The nurse must first identify why the patient is not following the therapy before collaboration with other health care professions, or changing the nursing care plan can be initiated. Simply explaining the effects of a high-salt diet and smoking on the blood pressure may not address the underlying cause of why the patient is choosing not to follow the recommended care. (less)

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. 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. (less)

A client cannot afford the treatment prescribed. Who would be the most appropriate professional for the nurse to involve with the client's care?

Nurse case manager The nurse case manager is the expert on resources available for the client's care. The nurse manager is responsible for the operation of the nursing unit. The physician is concerned with the client's medical needs. The insurance company is a possible resource, if the client has insurance coverage. (less)

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 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. (less)

The nurse is caring for Mr. M., a 48-year-old man with congestive heart failure. The nurse manager informs the nurse that Mr. M. 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 evaluation An outcome evaluation determines the extent to which a client's behavioral response to a nursing intervention reflects the outcome criteria.

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

The emergency room has a strict protocol regarding IM (intramuscular) injection technique. A nurse working in the emergency room has learned of a new technique to decrease pain with IM injections and would like to use it. What is the most appropriate way for the nurse to implement the technique?

Petition to change the protocol based on the new evidence. The nurse should petition to change the protocol on the basis of the new evidence. If the nurse feels that the change would be beneficial to clients, it is important to change the procedure for all clients. Therefore, having the ER physician write orders would not effect all clients. Since the nurse must function under the protocols of the agency, it would be wrong to begin using the technique before the protocol is changed. Protocols at other area emergency rooms is not relative to the issue. (less)

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 his care. Clients should be empowered to take responsibility for self-care. All clients should be taught that they have the power to question any part of their care. The nurse would appropriately praise the client. It is necessary to wash hands before taking vital signs; gloves are not required for the procedure. Telling the client that the nurse knows when to perform hand hygiene is disrespectful of the client's concern. (less)

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?

Revise the care plan to allow the client to ambulate to the bathroom independently. 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. (less)

The nurse is caring for a postoperative client who is receiving morphine sulfate for pain management. The nurse obtains the following vital signs. HR 74 RR 8 BP 114/68. After reviewing the nursing care plan and physician orders, the nurse administers naloxone (Narcan). What would allow the nurse to initiate this action?

Standing orders Standing orders allow the nurse to initiate action that ordinarily require the order of a physician, such as administer naloxone. An algorithm is a binary decision tree that guides stepwise assessment and intervention for a high-risk subgroup of clients. A protocol is a written plan that details nursing activities to be executed in specific situations. An order set is a preprinted set of provider orders that expedite the provider order process. (less)

The nurse is working with Ms. V. today. Ms. V. is having a difficult time accepting her new diagnosis of type 2 diabetes. Thenurse pulls up a chair next to Ms. V.'s bed and holds her hand while listening to her story. What type of nursing intervention is the nurse engaging in?

Supportive intervention Supportive interventions emphasize use of communication skills, relief of spiritual distress, and caring behaviors. Psychosocial interventions focus on resolving emotional, psychological, or social problems. Coordinating interventions involve many different activities, such as acting as a client advocate and making referrals for follow-up care. Supervisory interventions refer to overseeing the client's overall health care. (less)

Nurse Mayweather is auscultating lung sounds. She notes crackles in the LLL which were not present at the start of the shift. Nurse Mayweather is engaged in which type of nursing intervention?

Surveillance intervention Surveillance interventions include detecting changes from baseline data and recognizing abnormal response. Nurses rely on the senses to detect changes: observing the appearance and characteristics of clients; hearing by auscultation, pitch, and tone. Nurses use these surveillance activities to determine the current status of clients and changes from previous states. (less)

While observing a new nurse inserting an indwelling urinary catheter, the preceptor observes a break in sterile technique. What is the preceptor's best first action?

Tell the new nurse that a break in sterile technique has occurred and the procedure must be stopped. The most important priority is to ensure the client's safety. Since the new nurse has contaminated the sterile field, the risk of introducing infection is high. The procedure must be discontinued. Since the preceptor is working with the new nurse, it would not be necessary to report the new nurse's error to the nurse manager unless it became a pattern of behavior. Assigning the nurse to watch instructional videos might be appropriate, but after the client care issue is resolved. (less)

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?

Tell the student that the RN will assist the student with the client's ambulation. 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. (less)

A client who has been in a vegetative state for years is scheduled for an elective surgery. The nurse is questioning whether the procedure is necessary. What is the nurse's most appropriate first action?

The nurse should address the concern with the surgeon. The nurse should first address the concern with the surgeon who has scheduled the procedure. If the nurse still has concerns after the discussion with the surgeon, the other choices are possible courses of action. (less)

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

an asthma client who reports shortness of breath with a respiratory rate of 26 bpm 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 education 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. (less)

Which examples of nursing actions involve direct care of the client? Select all that apply.

• A nurse massages the back of a client while performing a skin assessment. • A nurse helps a client in hospice fill out a living will form. • A nurse counsels a young family who is interested in natural family planning. A direct care intervention is a treatment performed through interaction with the client(s). Direct care interventions include both physiologic and psychosocial nursing actions, and include both the "laying of hands" actions and those that are more supportive and counseling in nature. 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. (less)

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. Delegation to unlicensed assistive personnel (UAP) requires knowledge of the RN role and what tasks can be legally delegated. 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 education to the client or 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. (less)

Nurses implement care for clients in various health care settings. Which activities would typically be carried out during the implementation step of the nursing process? Select all that apply.

• Collecting additional client data • Modifying the client plan of care During the implementation phase the nurse carries out the plan of care, continues data collection, modifies the plan of care as needed, and documents the care provided. Performing an initial assessment and a database is a component of the assessment (data collection) phase of the nursing process. Developing client outcomes and goals is part of the planning phase. Measuring achievement of goals is part of the evaluation phase of the nursing process. (less)

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 denies the need for education. • The client is blind. 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. (less)

What assessment data would indicate to the nurse at the conclusion of an education session that the client education was effective? Mark 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. After an intervention is implemented, the nurse must assess the effectiveness of the intervention. The client stating an understanding of the instructions gives the nurse an indication that learning has taken place. Asking the client questions and receiving the correct answers is an excellent way to judge the client's knowledge. The client asking for the nurse to repeat the instructions shows that the client does not have a clear understanding. The client's statement that his wife will handle his care signals that the client is not ready to learn at this time. The client's ability to discuss the specifics of the material suggests that learning has taken place. (less)

The client is having difficulty breathing. The respiratory rate is 44 and the oxygen saturation is 89%. The nurse raises the head of the bed and applies oxygen at 3L/min per nasal cannula. How does the nurse determine the effectiveness of the interventions? Mark all that apply.

• The client's respiratory rate decreases. • The client's oxygen saturation level increases. • The client states, "I can breathe easier now." When reassessing the client after implementing interventions to increase oxygenation, the nurse would look for a decrease in respiratory rate to more normal rate and an increase in the oxygen saturation level. The client's subjective statement of breathing easier would also indicate effectiveness. The client watching television and the client's family's statement do not indicate anything about oxygenation status. (less)

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. 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 his understanding of the instructions. The other steps might be interventions that the nurse would institute after determining the client's needs. (less)

As part of the plan of care, a nurse administers scheduled pain medication to a postoperative 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. 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 client's pain level before ambulating the client. Giving a p.r.n. dose of analgesic for breakthrough pain first requires assessment of the pain level. (less)

One hour after receiving pain medication, a postoperative client reports intense pain. What is the nurse's most appropriate first action?

Assess the client to determine the cause of the pain. One hour after administering pain medication, the nurse would expect the client to be relieved of pain. A new report of intense pain might signal a complication and requires a thorough assessment. The nurse might request an order for additional pain medication, but only after a thorough assessment. Telling the client how often medication can be received does not help relieve the client's pain. Repositioning and splinting the incision are interventions that the nurse might perform, but only after determining the cause of the pain. (less)

One hour after receiving blood pressure medication, the client reports feeling lightheaded and dizzy. What is the nurse's best first action?

Assess the client's blood pressure. When the nurse administered the blood pressure medication, the nurse was aware of possible adverse reactions. When the client reports feeling dizzy and lightheaded, the nurse's most appropriate action is to assess to see if hypotension is the cause of the client's discomfort. Assessing the client's blood glucose level and reviewing the results of lab testing would be additional steps to determine the cause of the client's symptoms. The nurse would not convey the client's report of feeling dizzy to the physician until the assessment was complete. (less)

The home health nurse caring for a client with limited eyesight notes that the client's route to the bathroom is cluttered. What is the most effective way for the nurse to ensure the client's long-term safety?

Assist the client to identify strategies to promote safety in the home. The best way to address safety in the home is to discuss the issue with the client. Since the client has a visual deficit, clutter in the pathway to the bathroom may not be the only hazardous condition in the home. Helping the client identify safety strategies will help the client be more independent and will promote safety in the long run. Removing the cluttered objects would be important for the client's immediate safety, but would not help keep the client safe in the long run. Instructing the client to keep the walkway clear without identifying ways to do it would not keep the client safe. A home health aide could be part of the overall strategy to help protect the client, but the aide will not be present all the time to protect the client. (less)

After instituting interventions to increase oxygenation, the client shows no signs of improvement. What is the nurse's priority action?

Communicate with the physician for additional orders. If the nurse's interventions have been ineffective, the physician must be notified of the client's deteriorating status. The physician can direct other medical interventions. Documenting the interventions does not take priority over the client's physiologic needs. Allowing another 30 minutes to elapse before taking action will only cause further deterioration in the client's status. The nurse should know the client's code status when taking over the client's care. (less)

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 physician. As coordinator of the client's care, the nurse functions as an intermediary between the physician and the client. In order to honor the client's wishes, the nurse would most appropriately consult with the physician 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. (less)

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. 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. (less)

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 most appropriate first action?

Go to the client and assess the client's pain. The nurse's first action should always be to determine the cause of the client's pain in order to determine the correct intervention. After determining the cause, the nurse can plan how to proceed. The other steps would be appropriate, but only after the assessment. (less)

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 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. (less)

A student nurse has reported for a clinical preceptorship in a hospital and has been reassigned from the medical surgical unit to a pediatric unit. The student nurse has never worked with pediatric clients. Which of the following actions should the student nurse take in this situation?

Inform the supervisor that she cannot accept this assignment because of a lack of experience with pediatric clients. The correct action in this situation is for the student nurse to inform the supervisor that she cannot accept the assignment since she is not competent working with pediatric clients. The student nurse cannot accept the assignment and only perform vital signs for the clients under her care. The student nurse cannot accept the assignment and then decide that she cannot competently care for the clients. Once the assignment has been accepted the student nurse has accepted responsibility for the clients until the end of her shift. This assignment is not an infraction of the nurse practice act. The student nurse has the option of not accepting the assignment. (less)

A nurse has delegated a task to an unlicensed assistive personnel (UAP) member. How will this nurse assure that this UAP understands the instructions to perform this task?

Instruct the UAP to repeat your instructions to be sure you have communicated clearly. Instruct the UAP to repeat your instructions to be sure you have communicated 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. (less)

The RN is orienting a new nurse who suggests a different way to perform a procedure. What is the RN's most appropriate reaction?

Listen to the new nurse's suggestion and evaluate its usefulness. It is appropriate for health care professionals to be constantly evaluating whether the client's needs are being met in the best way. The experienced nurse should listen to the ideas of the new nurse and decide if the approach would be beneficial to the client. If the nurse's initial reaction is to quote policy and procedure, it does not allow for the exchange of ideas with the new nurse. It would not be necessary to consult with another experienced nurse or with the client's physician. (less)

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 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. (less)

The nurse is to delegate certain tasks to unlicensed assistive personnel (UAP). Which of the following tasks can be appropriately assigned to a UAP?

Provide client assistance to the bedside commode. Assisting with toileting is one of the tasks permitted by the state board of nursing for UAP. This task is commonly performed by UAP in health facilities.

After learning about a client's limited financial resources and limited insurance benefits, the home care nurse modifies nursing interventions related to a client's care instructions. The nurse modifies the plan of care based upon which client variable?

Psychosocial background The nurse is demonstrating an awareness of the client's psychosocial background, which includes consideration of the client's socioeconomic status. Research findings and current standards of care are examples of nursing variables. Developmental stage is a client variable that addresses the developmental needs of a client. (less)

A nurse in the ICU (intensive care unit) has been assigned to care for a client who was seriously injured during a gang rape. The nurse was raped 6 months ago and feels that she will be too upset to care for the client properly. How should the nurse deal with the assignment?

Recognize her limitations and ask for another nurse to be assigned. The nurse should keep the client's best interests in mind. If the nurse feels that her emotional state would compromise the client's care, the best course would be for the nurse to request a different assignment. The other courses of action leave the possibility that the client's care could be compromised. (less)

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 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. (less)

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. If the family has experience caring for a child with a seizure disorder, the family would already have some basic knowledge, so the nurse would address the education differently. The client expressing a desire to learn indicates receptiveness to the education. The parents' acceptance of their child's condition indicates that they are ready to begin dealing with the child's condition. The fact that the child has comprehensive insurance coverage is a strength that will make options available to the family, but will not necessarily change the nurse's educational plan. (less)

The client has a diagnosis of Risk for Injury related to falls. How would the nurse know if the intervention was successful?

The client is free of falls. Interventions for risk diagnoses are directed at prevention. The most appropriate way to evaluate the success of the interventions is to determine if the risk was prevented. The best evaluation criteria would be if the client remained free of falls. The client calling for assistance might prevent a fall, but does not signify that a fall will not occur. Teaching clients safety precautions and having the client verbalize risk for injuries is important but does not necessarily mean that an injury is prevented. (less)

The Joint Commission encourages patients to become active, involved, and informed participants on the health care team. What nursing action follows TJC recommendations for improving patient safety by encouraging patients to speak up?

The nurse encourages the patient to participate in all treatment decisions as the center of the health care team. The Joint Commission (TJC) encourages patients to become active, involved, and informed participants on the health care team. By becoming involved and "speaking up" research shows that patients who take part in decisions about their health care are more likely to have better outcomes. The nurse should never want to prevent patient questions. While patients are encouraged to be independent, trusted family members and friends can be an asset to the patient's care. The nurse should investigate the possibility of an error if the patient questions the nurse about a medication. (less)

When caring for a client in the emergency room who has presented with symptoms of a (MI) myocardial infarction, the nurse orders laboratory tests and administers medication to the client before the physician has examined the client. In order for the nurse to be operating within the nurse's scope of practice, what conditions must be present?

The nurse is operating under standing orders for clients with MIs. In order for the nurse to administer medications or order laboratory tests, the nurse must have a physician's order. In special circumstances, such as in the emergency room, there are standing orders in place to authorize the nurse's actions in certain situations. The other three statements may also be true, but they do not give the nurse the authority to institute these actions independent of a physician's order. (less)

A registered nurse (RN) and a licensed practical nurse (LPN) are caring for a client who has been admitted with an acute exacerbation of chronic obstructive pulmonary disease (COPD). Which nursing actions can the RN delegate to the LPN? Select all that apply.

• Obtaining pulse oximetry • Auscultating breath sounds • Administering nebulizer treatment It is within the scope of practice for a licensed practical nurse (LPN) to obtain pulse oximetry, auscultate breath sounds, and administer nebulizer treatments. A registered nurse (RN) must perform the admission assessment and develop the nursing care plan. These are tasks that cannot be delegated because these are not in the scope of the LPN. (less)

A busy nurse is working with an unlicensed assistive personnel (UAP). What tasks can the nurse appropriately delegate to the UAP? Mark all that apply.

• Record the client's intake and output. • Assist the client to the bedside commode It is crucial for the nurse to be aware of the legalities of delegation to unlicensed assistive personnel. Appropriate delegation to a UAP would include recording intake and output and assisting the client to the bedside commode. Assessment of the client's educational needs and the risk for pressure ulcers fall only under the nurse's scope of practice. Administering oral medications is not appropriate for unlicensed assistive personnel. (less)

Nurses use the Nursing Outcomes Classifications when choosing nursing goals for patients. What are the goals of the research that is behind the Nursing Outcomes Classifications (NOCs)? (Select all that apply.)

• To identify, label, and validate nursing-sensitive patient outcomes and indicators • To define and test measurement procedures for the outcomes and indicators • To evaluate the validity and usefulness of the classification in clinical field testing The goals of research behind the NOC is to identify, label, validate, and classify nursing-sensitive patient 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. This research continues in an effort to develop a common nursing language to optimize the design and delivery of safe, high-quality, and cost-effective care. Teaching decision making and ensuring proper reimbursement are not goals of the NOC. Communicating nursing to non-nurses is a goal of the Nursing Interventions Classification (NIC). (less)

An unlicensed assistive personnel (UAP) has worked on the postpartum unit for many years. The UAP has been oriented well and provides excellent client care. What duties could the professional nurse appropriately delegate to the UAP? Select all that apply.

• assisting the client with personal hygiene needs and ambulation • transporting the infant to the mother's room according to hospital policy It is essential when delegating duties that the RN is aware her role and what duties can be delegated. The nurse also must be aware of the training and the competence of the UAP. The nurse could appropriately delegate assisting with personal hygiene needs, ambulation, and transporting the infant to the mother's room according to hospital policy. Assessment is the role of the RN and cannot be delegated. Teaching, including breastfeeding education and discharge instructions, is also the role of the RN and cannot be delegated. (less)