Fundamentals- Ch. 17

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." p.424

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. pg.424

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 physician's order Explanation: Oxygen administration is a dependent nursing intervention because it requires a physician's order. Independent nursing interventions 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. Collaborative and interdependent are not types of nursing interventions. p.422

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. p.417

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. p.427

The nurse is preparing a client to be discharged from the surgical unit following abdominal surgery. Which intervention will the nurse use to ensure the client understands proper wound care techniques?

Include family members or other caregivers in the education . p.349

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?

Nursing assistant who is a nursing student p.429

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 p. 423

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. pp.416-417

A nurse is catheterizing a client. Which scenario demonstrates steps the nurse would take to ensure client respect and privacy?

Explain the procedure to the client, close the door to the room, and cover all areas of the client, only exposing the area for catheterization. p.422

Which action 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. p.416

A client recovering after an appendectomy is reporting pain. The nurse administers the ordered pain medication and assists the client to splint the incision. What is the nurse's next step in implementing the plan of care?

Reassess the client to determine the effectiveness of the interventions. p.417-419

Before implementing any planned intervention, which action should the nurse take first?

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. p.419

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. p.428

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. Explanation: 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. p.415

A nurse is providing care to several assigned clients and decides to delegate the task of morning vital signs to unlicensed assistive personnel. The nurse would assume responsibility and refrain from delegating this task for which client?

A client with a high fever receiving intravenous fluids, antibiotics, and oxygen pp. 428-429

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. p.431

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

Determine the client's willingness to follow the regimen. p.417-425

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 pp.415-429

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. p.422

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. Explanation: 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. p.419

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. p.419

Which is an independent (nurse-initiated) action?

Helping to allay a client's fears about surgery p.424-433

The primary purpose of nursing implementation is to:

help the client achieve optimal levels of health. p.414

The client is about to have blood drawn before seeing the health care provider. The spouse, while smiling and holding the client's hand, states, "Here comes the blood sucker. It is going to hurt bad." This statement is an example of which types of intervention? Select all that apply.

-Psychosocial -Supportive -Physical p.418

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 restaraunt 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. p.428

Which statement best explains why continuing data collection is important?

It enables the nurse to revise the care plan appropriately. p.428

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 Explanation: 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. p..417-426

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.

The emergency room (ER) has a strict protocol regarding intramuscular (IM) injection technique. A nurse working in the ER has learned of a new technique to decrease pain with IM injections from the nursing literature 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. Explanation: The nurse should petition to change the protocol on the basis of the new evidence. If the nurse believes 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 be the best choice because it would not affect all clients. Because 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 are not as authoritative as evidence from the nursing literature. p.419

What is the priority goal of interventions for a risk diagnosis?

Prevent an actual problem Explanation: 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. p.419

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 Explanation: 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. P.425

Which is is the priority activity for the nurse to perform in the implementation step of the nursing process?

Reassess client's needs. Explanation: The activities of implementation in order of priority are: (a) reassess, (b) set priorities, (c) perform nursing interventions, (d) record nursing actions. Differentiation between subjective and objective data is most associated with the assessment phase of the nursing process. p.417

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?

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. p.423

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. p.416

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

The nurse encourages the client to participate in all treatment decisions as the center of the health care team. pp.423-424

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 appropriate first action?

The nurse should address the concern with the surgeon. p.416-418

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." Explanation: 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. p.418-419

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 Explanation: It is essential when delegating duties that the registered nurse (RN) is aware the nurse's 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. p.428-429

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. p.422

What are the goals of the research that is behind the Nursing Outcomes Classification (NOC) system? Select all that apply.

-To identify, label, and validate nursing-sensitive client outcomes and indicators -To evaluate the validity and usefulness of the classification in clinical field testing -To define and test measurement procedures for the outcomes and indicators Explanation: The goals of research behind the NOC are to identify, label, validate, and classify nursing-sensitive client 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). p.416

Which nursing intervention 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 p.419

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. p. 428

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 Explanation: 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 UAP's 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. p.428

A client on the medical-surgical unit is scheduled for several diagnostic tests. The nurse is concerned that the tests will be too tiring for the client. What would be the nurse's most appropriate action?

Coordinate with the other disciplines to schedule the tests with adequate rest for the client. pg.416

A client has terminal cancer and the primary care provider has ordered a diagnostic imaging test. The client does not want the test performed so the nurse agrees to dialogue with the primary care provider on the client's behalf. The nurse's actions are what type of intervention?

Coordinating Explanation: Coordination involves acting as a client advocate, making referrals for follow-up care, collaborating with other health care team members, and ensuring that the client's schedule is therapeutic. This is not a surveillance or technical type of intervention. The nurse is being supportive of the client, but advocacy is more closely associated with coordinating types of interventions. p.416-417

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?

Delay the instruction until the visitors leave. p.419

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. p.416

The nurse in a burn intensive care unit (BICU) is caring for a 3-year-old child who was burned with scalding hot water. The client has burns covering 75% of the body. The client's condition is critical but stable. At 1000, the nurse reassesses the client and finds that the client is agitated and pulling at the endotracheal tube. Which is the nurse's priority intervention for this client at this time?

Ensuring that the endotracheal tube is secure pp. 427-430

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. p.419

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. pp.419-428

Which nursing action would be most effective in helping a client learn self-care behaviors?

Model self-care behaviors for the client. Explanation: Modeling self-care behaviors is a nursing intervention and is the action most effective in helping the client learn the self-care behaviors. The other answer options refer to evaluation of the client's response to interventions related to learning self-care behaviors. p.424

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. p.428

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. p.431

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." p.423

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. Explanation: The best way to address safety in the home is to discuss the issue with the client. Because 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. p.422

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

Auscultating of 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 physician 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 intervention. p.417-428

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. Explanation: 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. p.417

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. Explanation: 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. P.416-418

Which is the priority question for the nurse to consider before implementing a new intervention?

Does this treatment make sense for this client? p.419

Which action is a nursing intervention that facilitates lifespan care?

Educate family members about normal growth and development patterns. p.414

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. p.416-419

The nurse is preparing a client with a bowel obstruction for emergency surgery. Which intervention has the highest priority for this client?

Inform the client what to expect after the surgery. p. 424

A nurse is administering metformin to a client who has a new onset of diabetes mellitus type 2. Which step should the nurse consider a priority on the nursing care plan?

Monitor for lactic acidosis Explanation: In this scenario, the nurse is administering a medication. Because an action is being carried out, this is the implementation step of the nursing process. Following the administration of medication, the nurse should monitor the client for lactic acidosis as well as side effects of the medication. Restricting the client's food and fluids while the client is on metformin is only suggested when the client is preparing for a procedure requiring the client to be NPO. B12 injections may be indicated in the future as treatment has been established. Likewise, it is too early in the treatment plan to monitor for noncompliance. p.414-426

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 Explanation: A sufficient number of nurses are needed to respond to the disaster. The department is functional and is not full of clients. Sufficient supplies are available. p.422

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. p.417

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. p.428

The registered nurse (RN) is delegating the task of assisting a postoperative client to the bathroom to the unlicensed assistive personnel (UAP). The nurse witnessed the UAP correctly perform the task on previous occasions and knows the UAP is competent to perform the task. The nurse has communicated how to get the client out and back into bed and told the UAP not to allow the client to bear weight on the left leg. The nurse validated that the activity was completed and gave the UAP feedback. Which delegation guideline did the nurse omit?

Right circumstance p.429

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 p.419

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

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. p.415

The nursing team, consisting of a nurse and experienced unlicensed assistive personnel (UAP), have worked well together for the past year. 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 in addition to notifying the nurse if the blood pressure becomes low. Which error has the nurse made?

The nurse failed to communicate clear instructions regarding what constitutes a low blood pressure. Explanation: The nurse failed to communicate clear instructions to the UAP. The delegated tasks are not too numerous and are within the scope of a 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. p.428-429

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

-A nurse counsels a young family who is interested in natural family planning. -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. Explanation: 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. p.418

Which tasks can the nurse appropriately delegate to the unlicensed assistive personnel (UAP)? Select all that apply.

-Record the client's intake and output. -Assist the client to the bedside commode. Explanation: It is crucial for the nurse to be aware of the legalities of delegation to UAPs. 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 injuries fall only under the nurse's scope of practice. Administering oral medications is not appropriate for UAPs. p.428-432

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. Explanation: 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. p.424

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

Recognize the nurse's own limitations and ask for another nurse to be assigned. Explanation: The nurse should keep the client's best interests in mind. If the nurse feels that the nurse's 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.

The nurse is caring for a postoperative client who is receiving morphine sulfate for pain management. The nurse obtains the following vital signs: heart rate, 74 beats/min; respiratory rate, 8 breaths/min; blood pressure, 114/68 mm Hg. After reviewing the nursing care plan and physician orders, the nurse administers naloxone. Which would allow the nurse to initiate this action?

Standing orders Explanation: Standing orders allow the nurse to initiate actions that ordinarily require the order of a physician, such as administering 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. p.419

A client with diabetes who has been closely following the prescribed plan of care for over a year is being seen at an outpatient facility. 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." Explanation: 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 why the care regimen has not been followed. p.429

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. p.417-425

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?

Nursing assistant p.429

When caring for a client in the emergency room who has presented with symptoms of a myocardial infarction (MI), the nurse orders laboratory tests and administers medication to the client before the physician has examined the client. 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 suspected MIs. Explanation: 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. p.419

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. Explanation: 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. p.418

The nurse failed to communicate clear instructions to the UAP. The delegated tasks are not too numerous and are within the scope of a 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.

Collaborate with the nutritionist to modify the nutritional plan. Explanation: A vegetarian does not consume animal proteins. Although animal proteins are an important source of iron, plant proteins are available. To honor the preferences of the client, the nurse would collaborate with the nutritionist to include these plant sources of protein in the client's diet (instead of the animal protein). It is not true that the client has to consume animal protein to cure the anemia. Meeting with the client's family would be inappropriate because this would violate the wishes of the client. Arranging for animal protein to be disguised in the client's meal would violate the client's trust and would also not be effective in the long term after the client has been discharged. p.431

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. p. 416