Implementing

The nurse is caring for a client admitted to the hospital for renal calculi. What is the action to take first?

Assess for bladder distention. Urinary retention could occur if a kidney stone has become lodged in the urethra. Forcing fluids, straining the urine after each void, and diet as tolerated are appropriate interventions, but these do not address the safety issue of first assessing the bladder for distension; this could potentially cause the client discomfort and harm.

A client being treated with chemotherapy for breast cancer tells the nurse that she no longer wants to receive the medication because of the overwhelming nausea and vomiting. How should the nurse respond to the client's statement?

Consult with the physician to treat the client's nausea. The client has stated that the nausea and vomiting are causing her to want to discontinue the chemotherapy. The most appropriate action by the nurse is to confer with the physician to treat the client's discomfort. After the nausea and vomiting are gone, the client can decide if she wants to continue with the chemotherapy. Simply informing the physician that the client wants to discontinue the therapy is only giving part of the information. Reviewing the possible results of discontinuing the chemotherapy does not answer the client's concern. It is not appropriate to discuss the client's condition with the family without the client's consent.

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

Determine the client's willingness to follow the regimen. The prerequisite to health education about self-care after cataract surgery is the client's willingness to follow the regimen. Once a nurse is aware of the client's readiness for learning, the nurse can implement outcome-based education plans. Identifying changes from baseline is important for monitoring interventions. Approval by the physician may not be necessary. Delegating the teaching activity to an unlicensed assistive personnel (UAP) is inappropriate because it is not in accordance with her capabilities.

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 nurse needs further information before deciding what interventions are necessary, so the most appropriate action is to determine the client's reasons for refusal. Until the information is collected, the nurse cannot decide whether reviewing the risks and benefits of surgery would be effective. It is also premature to ask the client to discuss the decision with family members. It is not appropriate to notify the physician until the assessment is complete.

The RN is orienting a new nurse who suggests a different way to perform a procedure. What is the RN's most appropriate reaction?

Listen to the new nurse's suggestion and evaluate its usefulness.

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.

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 Surveillance nursing interventions include detecting changes from baseline data and recognizing abnormal responses.

The RN is orienting a new nurse who suggests a different way to perform a procedure. What is the RN's most appropriate reaction?

Listen to the new nurse's suggestion and evaluate its usefulness. It is appropriate for health care professionals to be constantly evaluating whether the client's needs are being met in the best way. The experienced nurse should listen to the ideas of the new nurse and decide if the approach would be beneficial to the client. If the nurse's initial reaction is to quote policy and procedure, it does not allow for the exchange of ideas with the new nurse. It would not be necessary to consult with another experienced nurse or with the client's physician.

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.

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 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. The nurse must encourage the client to provide as much self-care as possible in order to achieve the highest level of independence. Performing all care activities for the client makes the client dependent on the nurse. If the family anticipates and meets all the client's needs, this also hinders the client's recovery. An early discharge is not indicated because the client must be sufficiently recovered.

Which of the following nursing interventions 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 Standing orders and protocols often surround the management of bowel elimination. Modification of a client's IV fluid or administration of a new antihypertensive are client-specific interventions that are physician initiated. The care team cannot independently change a client's advance directive.

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. If the nurse suspects a client does not understand instructions, the first step is to assess the client's understanding. The most effective way to do that is to have the client repeat his understanding of the instructions. The other steps might be interventions that the nurse would institute after determining the client's needs.

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?

Equipment and personnel A key component of the organizing interventions is to ensure adequate equipment (extra supplies) and sufficient personnel to assist with more complex tasks.

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

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

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 26 bpm According to the ABC priority framework, the client who should be assessed first is the asthma client with shortness of breath and a respiratory rate of 26 bpm. The appendectomy client with an elevated temperature should be assessed for suspected infection. However, this is not the priority action. The diabetic client should receive education regarding administration of insulin but this is not a priority. The hysterectomy client should be assessed for possible hemorrhage. However, according to the ABC priority framework, this is not the priority.

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. 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.

Nurse Mayweather is auscultating lung sounds. She notes crackles in the LLL which were not present at the start of the shift. Nurse Mayweather is engaged in which type of nursing intervention?

Surveillance intervention Surveillance interventions include detecting changes from baseline data and recognizing abnormal response. Nurses rely on the senses to detect changes: observing the appearance and characteristics of clients; hearing by auscultation, pitch, and tone. Nurses use these surveillance activities to determine the current status of clients and changes from previous states.

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.