NUR FUND Chapter #14 + PREP U

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?

- Reschedule the client's bath to the evening shift. p. 242 Rationale: The client's preferences are a primary consideration in scheduling interventions. The client's preference to have a bath at night requires a change in scheduling. Asking for permission to give the bath in the morning does not address the client's preference. The schedule of the nurses should not take priority over client needs. Informing the client about sleep medication does not address the client's preference.

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 p. 246 Rationale: 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.

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.

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. 242 Rationale: One hour after administering pain medication, the nurse would expect the client to be relieved of pain. A new report of intense pain might signal a complication and requires a thorough assessment. The nurse might request an order for additional pain medication, but only after a thorough assessment. Telling the client how often medication can be received does not help relieve the client's pain. Repositioning and splinting the incision are interventions that the nurse might perform, but only after determining the cause of the pain.

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 ask the client for permission to teach a family member. Continue the education and remind the client that it is essential to learn self-care . Discontinue the education and attempt at another time. Medicate the client for anxiety and continue the education later.

Discontinue the education and attempt at another time.

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 the alternative options with the doctor

Priority setting is based on the information obtained during reassessment. Priority setting is used to rank nursing diagnoses. Each of the following contributes to priority setting except which of the following?

Finances of the client p. 242 Rationale: Each of these factors contributes to the prioritization of nursing diagnoses except the client's finances. The nursing code of ethics states that clients receive the same treatment regardless of their ability to pay.

A client is diagnosed with hypertension and placed on a low sodium diet and given smoking cessation literature. The nurse observes the client eating from a fast food restaurant 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 patient?

Identify what barriers the client feels are preventing adherence with the plan.

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.

The nurse is caring for Mr. M., a 48-year-old man with congestive heart failure. The nurse manager informs the nurse that Mr. M. 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 evaluation

Prior to the first postoperative visit post gastrectomy, the client will have a weight loss of 10 lb (4.50 kg). This is an example of which type of evaluative statement?

Physical changes Explanation: Psychomotor outcomes are those that are related to new skill attainment , cognitive outcomes are related to achieving greater knowledge, affective outcomes are related to feelings and attitudes and physical changes are related to actual body changes in the individual which is represented by the 10 lb weight loss..

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.

Mr. J. is a 56-year-old man status post admission for a myocardial infarction and coronary artery bypass graft. He is preparing to go home tomorrow. Mr. J. expresses that he feels unprepared to cook heart-healthy foods. The nurse sits with Mr. J. and reviews the heart-healthy nutrition plan, asking him to identify which foods would be appropriate for him to eat. What type of nursing intervention is the nurse engaging in?

Supervisory intervention

Which of the following is a nursing intervention that facilitates life span care?

Teach family members normal growth and development patterns.

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.

Which client outcome is a cognitive outcome? Select all that apply.

The client lists the side effects of digoxin (Lanoxin). • The client describes how to perform progressive muscle relaxation. • The client identifies signs and symptoms of hypoglycemia. Explanation: Cognitive outcomes demonstrate increases in client knowledge, such as listing side effects of medications, identifying signs and symptoms of hypoglycemia, and describing progressive muscle relaxation. A psychomotor outcome involves changes in the client's values, beliefs, and attitude. Psychomotor outcomes describe the client's achievement of new skills, such as correct ambulation with a walker. An affective outcome involves changes in the client's values, beliefs, and attitude, such as the client's report of cycling.

The nurse caring for a client who is recovering after a motor vehicle accident is planning for the client to begin increasing responsibility for self-care. What would be the nurse's most appropriate strategy?

The nurse encourages the client to take a shower instead of receiving a bed bath.

A nurse evaluates clients prior to discharge from a hospital setting. Which action is the most important act of evaluation performed by the nurse?

The nurse evaluates the patient's goal/outcome achievement. Explanation: The priority is to evaluate the patient's goal/outcome achievement. This determines if the nursing diagnosis has been resolved. If the patient's goal/outcome had not been met the nurse should then begin evaluating all aspects of the plan of care. It is not the responsibility of the nurse to evaluate the competence of nurse practitioners. The nurse can evaluate services available to the patient but his is not the purpose of the evaluation phase of the nursing process.

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 shift. What is the nurse's most appropriate course of action?

The nurse should inform the charge nurse that she does not have the experience to properly care for this client.

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 do this to ensure that we have the correct patient