Implementation (PrepU)

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."

An unlicensed assistive personal (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?

- Assisting the client with personal hygiene needs and ambulation - Transporting the infant to the mother's room according to hospital policy

A nursing student 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 26bpm

A client requires a change and reapplication of a colostomy bag. The nurse has never changed an ostomy bag before. What is the nurse's best course of action?

Ask a skilled nurse to assist with the procedure

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 indicated

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 the nursing instructor before performing the procedure

The mother of a pediatric patient 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 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

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 alternative to a blood transfusion with the physician

The client is in a rehabilitation unit after a traumatic brain surgery. 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

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

The primary purpose of nursing implementation is to...

Help the client acheive optimal levels of health

As the nurse bathes a client, she notes the skin color and integrity his ability to respond to simple directions, and his muscle tone. Which statement best explains why such continuing data collection is so important?

It enables the nurse to revise the care plan appropriately

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 reaction?

Praise the client for taking an active role in his care.

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, te client reports voiding in the bathroom. What is the nurse's most appropriate action?

Reassess if the urinary catheter is still necessary for the client

A client recovering after and appendectomy is reporting pain. The nurse administers the ordered pain medication and assists the client to split 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

The registered nurse (RN) is delegating the task of assisting a post-operative client to the bathroom to the unlicensed assistive personal (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 was omitted by the nurse?

Right circumstance

A 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

The nurse has assessed a client and determined that the client has abnormal sounds and low oxygen saturation level. The nurse is performing what type of nursing intervention?

Surveillance

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?

Technical skill