Fundamentals Ch 14

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

"I provide indirect care to my clients by coordinating their treatment with other disciplines."

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 indicate NOT Determine the client's reaction to the medication in the past.

Delegating responsibilities is one of the tools the nurse uses during client care. Which statement is appropriate when delegating?

Delegate tasks that follow the individual's scope of practice. Delegate tasks that involve minimal risk. Provide appropriate supervision when delegating tasks. Provide feedback after task is completed.

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 physician has ordered that the client should ambulate 3 times a day. The nurse enters the room to ambulate the client and the client reports pain. What is the nurse's most appropriate action?

Medicate the client and wait to ambulate later.

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. NOT just reteach them the same method

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 blind. The client denies the need for education. Not that the patient is married

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 is assigned a client who had 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?

Nursing assistant

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 NOT discharge anything

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

Assess the client's blood pressure.

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."

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.

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.

The registered nurse is working with an unlicensed assistive personnel. Which client should the nurse not delegate to the unlicensed assistive personnel?

TAhe client with continuous pulse oximetry who requires pharyngeal suctioning.

Which nursing action can be categorized as a surveillance or monitoring intervention?

auscultating of bilateral lung sounds Surveillance or monitoring nursing interventions includes 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.