Fundie's Ch. 14 Implementing

Which nursing intervention is appropriate for a risk nursing diagnosis? (Select all that apply). A. Prevent the problem B. Reduce or eliminate risk factors C. Monitor the client's status D. Promote higher-level wellness E. Collect additional data to rule out the diagnosis

A, B, & C

What assessment data would indicate to the nurse at the conclusion of an education session that client education was effective? (Mark all that apply). a. The client verbalizes understanding of the instructions b. The client asks the nurse to repeat the instructions c. The client is able to answer the nurse's questions d. The client tells the nurse that his wife will handle his care e. The client discusses the specifics of what was taught during the session.

A, C, & E

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 night shift. What is the nurse's most appropriate course of action? a. The nurse should ask another nurse who was previously assigned to the client for instruction b. The nurse should request that the blood transfusions be delayed until the next shift c. The nurse should inform the charge nurse that she does not have the experience to properly care for this client d. The nurse should recognize the necessity of the assignment and provide care to the best of her ability.

C

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. Which has the nurse failed to organize? A. Environment and client B. Logistics and planning C. Skills and assistance D. Equipment and personnel

D

The nurse is preparing a client with a bowel obstruction for emergency surgery. Of the following interventions, which has the highest priority? A. Discuss discharge plans with the client B. Teach the client about dietary restrictions during recovery C. Instruct the client and family in wound care D. Inform the client what to expect after the surgery

D

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? a. Coordinate with the other disciplines to schedule the tests with adequate rest for the client b. Coordinate with the other disciplines to determine if all the tests scheduled are necessary c. Review the physician's progress notes to determine if any of the tests are not indicated d. Instruct the client to refuse the diagnostic tests if the client becomes too fatigued.

A

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. Make changes in the plan of care based upon assessment data b. Ask the client's family to assist the client in following the plan of care. c. Provide information to the client on the benefits of complying with the plan of care. d. Discuss the desired outcomes with the client and the importance of the outcomes.

A

The nurse is preparing to give the client a bath early in the morning. The client states, "I prefer to take my bath at night, It helps me sleep." What is the nurse's most appropriate action? a. Reschedule the client's bath to the evening shift. b. Ask the client for permission to give the bath in the morning. c. Tell the client that the physician has ordered sleep medication if necessary. d. Determine if the nurses have time to give the client's bath at night.

A

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? a. Medicate the client and wait to ambulate later b. Ambulate the client and medicate later. c. Emphasize to the client the importance of following the treatment plan. d. Explain to the client the benefits of ambulation

A

The nurse has prepared to educate a client 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? a. Continue the education and remind the client that it is essential to learn self-care. b. Medicate the client for anxiety and continue the education later c. Discontinue the education and attempt at another time d. Discontinue the education and ask the client for permission to teach a family member

C

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 request pain medication. What is the nurse's appropriate first action? A. Determine the frequency of pain medication B. Medicate the client with the ordered pain medication C. Instruct the client in nonpharmacologic pain management D. Go to the client and assess the client's pain.

D