Foundations Chapter 17 PrepU

which nursing intervention is appropriate for a risk nursing diagnosis? select all that apply: a. monitor the clients status b. prevent the problem c. reduce or eliminate risk factors d. collect additional date to rule out the diagnosis e. promote higher-level wellness

-prevent the problem -reduce or eliminate risk factors -monitor the clients status

which nursing actions reflect the implementing step of nursing process? (select all that apply) a. determining the clients response to nursing interventions b. selecting culturally sensitive nursing interventions c. providing health education to reduce health risks d. referring the client to community resources, when necessary e. using evidence-based interventions individualized for the client

-providing health education to reduce health risks -referring the client to community resources, when necessary -using evidence-based interventions individualized for the client

which is a responsibility of the nurse in the nurse-health care team relationship? select all that apply: a. coordinate the inputs of the multidisciplinary team into a comprehensive plan of care b. support the nursing care given by other nursing personnel c. serve as a liaison between the client and family and the health care team d. educate the family to be informed and assertive consumers of health care e. provide creative leadership to make the nursing unit a satisfying and challenging place to work

-serve as liaison between the client and family and the health care team -coordinate the inputs of the multidisciplinary team into a comprehensive plan of care

which are essential components for delegating nursing care? select all that apply: a. the unlicensed assistive personnel evaluates the clients response after implementing the task, then reports to the nurse b. the task is delegated to a person with sufficient knowledge and skill for completing the task c. the unlicensed assistive personnel can verbalize what information is to be reported to the nurse d. the nurse seeks input from the unlicensed assistive personnel in planning the clients care for the shift e. instructions have been clearly communicated by the nurse to the unlicensed assistive personnel

-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

which of the following nursing interventions is most likely to be allowed within the parameters of a protocol or standing order? a. changing a clients IV fluid from normal saline to 5% dextrose b. administering a glycerin suppository to a constipated client who has not responded to oral stool softener c. administering a beta-adrenergic blocker to a new client whose blood pressure is high on admission assessment d.changing a clients advance directive after his prognosis has significantly worsened

administering a glycerin suppository to a constipated client who has not responded to oral stool softener

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? a. administer p.r.n. pain medications in 60 minutes b. assess pain level in 30 minutes c. assess respirations in 40 minutes d. ambulate the client in 20 minutes

assess pain level in 30 minutes

one hour after receiving blood pressure medication, the client reports feeling lightheaded and dizzy. what is the nurses first action? a. assess the clients blood pressure b. convey the clients report of dizziness to the physician c. assess the clients blood glucose level d. review the results of laboratory testing

assess the clients blood pressure

a nurse is catheterizing a client. which action illustrates respect for the clients privacy? a. asking another nurse if they want to watch b. closing the door to the room c. leaving the clients pajamas on d. explaining the procedure to the family

closing the door to the room

A staff nurse has asked the nursing student to perform an intervention that the nursing student has not been educated to perform? what is the appropriate approach for the nursing student to take? a. perform the procedure and inform your instructor of the results b. consult with your nursing instructor before performing the procedure c. delegate the intervention to an unlicensed assistive personnel member d. review the procedure in the procedure manual before performing the intervention

consult with your nursing instructor before performing the procedure

a nurse is preparing to educate a client about self-care after a cataract surgery. which of the following would the nurse do first? a. instruct the unlicensed assistive personnel on what to teach the client b. determine the clients willingness to follow the regimen c. ensure physician approval for the education plan d. identify changes from the baseline

determine the clients willingness to follow the regimen

a female client 89 years of age has been admitted to the hospital with a diagnosis of failure to thrive. she has become constipated in recent days, in spite of maintaining a high fluid intake and taking oral stool softeners. she admits to her nurse that the problem is rooted in the fact that she feels mortified to attempt a bowel movement on a commode at her bedside, where staff and other clients can hear her. the nurse should respond by modifying which of the following resources. a. client and visitors b. personnel c. environment d. equipment

environment

the nurse is attending a conference on evidence-based practice. which statement by the nurse indicates further education is needed? a. nursing interventions should be supported by a sound scientific rationale b. the agency for health research and quality is a resource for evidence-based practice c. i can learn about evidence-based practice by reading professional nursing journals d. i must conduct research to validate the usefulness of my nursing intervention

i must conduct research to validate the usefulness of my nursing interventions

after learning about a clients limited financial resources and limited insurance benefits, the home care nurse modifies nursing interventions related to a clients care instructions. the nurse modifies the plan of care based upon which client variable? a. research funding b. psychosocial background c. development stage d. current standards of care

psychosocial background

an indwelling urinary catheter has been ordered for a client experiencing urinary retention after surgery. when the nurse enters the room to place the catheter, the client reports voiding in the bathroom. what is the nurses most appropriate action? a. instruct the client that the catheter is essential to check for urinary retention b. reassess if the urinary catheter is still necessary for the client c. insert the urinary catheter as ordered to relieve the urinary retention d. inform the client that the catheter will no longer be necessary

reassess if the urinary catheter is still necessary for the client

a nurse on duty finds that a client is anxious about the results of laboratory testing. which intervention by the nurse reflects a supportive intervention? a. telling the laboratory technician to speed up the results b. calling the physician for an order for an anxiolytic c. educating the client about reducing risk factors d. sitting with the client to encourage her to talk

sitting with the client to encourage her to talk

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? a. standing orders b. order set c. algorithm d. protocol

standing orders

The registered nurse is working with an unlicensed assistive personnel. which client should the nurse not delegate to the unlicensed assistive personnel? a. the client who is pleasantly confused and requires assistance to the bathroom b. the client who requires assistance dressing in preparation for discharge c. the client who needs vital signs taken following infusion of packed red blood cells d. the client with continuous pulse oximetry who requires pharyngeal suctioning

the client with continuous pulse oximetry who requires pharyngeal suctioning

a nurse is administering metformin to a client who has a new onset of diabetes mellitus type 2. which of the following steps of nursing process is the nurse using? a. implementation b. planning c. evaluation d. assessment

implementation

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 a. ask another UAP to observe and assist the UAP in performing the task b. inform the UAP of the importance of following each step listed in the procedure manual c. instruct the UAP to repeat the instructions to be sure the nurse has communicated clearly d. request that the UAP place the steps of the task in the framework of the nursing process

instruct the UAP to repeat the instructions to be sure the nurse has communicated clearly

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? a. discuss the desired outcomes with the client and the importance of the outcomes b. provide information to the client on the benefits and complying with the plan of care c. make changes in the plan of care based upon assessment data d. ask the clients family to assist the client in following the plan of care

make changes in the plan of care based upon assessment data

the nurse is assessing a client with a diagnosis of hypertension. the clients blood pressure is 178/88, an increase from 134/78 at the previous clinic visit. the nurse asks the client what has changed from the previous visit. which client statement identifies a potential factor interfering with the plan of care? a. i have been taking my hydrochlorothiazide every day b. i have learned to prepare foods differently so they are low in fat c. my neighbor walks with me around the neighborhood every morning d. my husband has been ill and i dont have anyone help me care for him

my husband has been ill and i dont have anyone to help me care for him

the nurse is assigned a client who has an uneventful colon resection two days ago and requires a dressing change. to which nursing team member should the nurse avoid delegating the dressing change? a. a senior nursing student present for clinical b. licensed practical nurse c. nursing assistant d. registered nurse

nursing assistant

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? a. a senior nursing student present for clinical b. licensed practical nurse c. registered nurse d. nursing assistant who is a nursing student

nursing assistant who is a nursing student

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 slo 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 apartment manager need to organize to respond to the disaster? a. personnel b. environment c. equipment d. clients

personnel

the nurse caring for a client who is recovering after a motor vehicle accident is planning for the client to begin increasing responsibility for self-care. what would be the nurses most appropriate strategy? a. the nurse encourages the client to take a shower instead of receiving a bed bath b. the nurse consults with the physician to plan an early discharge c. the nurse instructs the family to stop performing tasks for the client d. the nurse tells the client that recovery is progressing too slowly

the nurse encourages the client to take a shower instead of receiving a bed bath

Implementation of the plan of care is most successful when: a. the nurse includes family members and other health care professionals b. the nurse takes on care and decision making for the client c. the nurse avoids further collecting of data until the evaluation phase d. the nurse recognizes documentation will occur during another phase

the nurse includes family members and other health care professionals