(PrepU) Chapter 17: Implementing

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 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.

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. It is the nurse's responsibility to revise the plan of care if an intervention is not successful. The most appropriate action of the nurse would be to determine if the initial education was the most effective for this client. Simply teaching the content again without reassessing the client's needs would not necessarily be effective. A support group might be helpful, but not until the client's needs are evaluated. The case manager is not responsible for the client's learning.

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 For delegation, the circumstances must be right. The health condition of the client must be stable. The client with a high fever receiving intravenous fluids, antibiotics, and oxygen is the least stable of the clients listed and should be assessed by the nurse. Delegation of taking vital signs would be appropriate for all of the other client's described.

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 the client's understanding of the instructions. The other steps might be interventions that the nurse would institute after determining the client's needs.

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 The nurse should avoid delegating the dressing change to the nursing assistant. The dressing change would be within the scope of practice of the registered nurse, licensed practical nurse, and the senior nursing student.

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. As coordinator of the client's care, the nurse functions as an intermediary between the physician and the client. In order to honor the client's wishes, the nurse would most appropriately consult with the physician to meet the client's physical needs, as well as the client's spiritual needs. The risk and benefits of a blood transfusion are not the relevant issue with the client. Discussing the client's options with other church members would violate the client's privacy and would not meet the client's physical needs. It might be advisable to discuss the client's refusal of care with the hospital risk manager to protect the legal requirements of the institution, but it is not the priority.

The nurse has administered pain medication to a client with a fractured femur. One hour later, the client reports relief of pain. What parameters would the nurse document to support evaluation of pain management?

Effectiveness of intervention including current pain scale, time frame, and client self-report. Because the client has reported the effectiveness of the intervention, the next step in implementation is to correctly complete the documentation including client's self-reporting of current pain descriptives, pain scale rating, and how effective interventions have been. Pain medication has not been decreased so this would not support interventions. Likewise, the client has experienced relief so documenting length of time between requests is not what is required at this time. Alternative pain management modalities are not the focus so this would not be appropriate.

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. 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. Maintenance nursing interventions involve the nurse assisting the client with performing routine activities of daily living. Supportive nursing measures involve providing basic comfort and emotional care to the client. Collaborative nursing interventions involve coordination and communication with health care professionals in other fields to meet the client's needs.

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. After an intervention is implemented, the nurse must assess the effectiveness of the intervention. The client stating an understanding of the instructions gives the nurse an indication that learning has taken place. Asking the client questions and receiving the correct answers is an excellent way to judge the client's knowledge. The client asking for the nurse to repeat the instructions shows that the client does not have a clear understanding. The client's statement that the spouse will handle the care signals that the client is not ready to learn at this time. The client's ability to discuss the specifics of the material suggests that learning has taken place.

The nurse is assessing a client with a diagnosis of hypertension. The client's blood pressure is 178/88 mm Hg, an increase from 134/78 mm Hg at the previous clinic visit. The nurse asks the client what has changed from the previous visit. Which client statement identifies a potential factor interfering with the plan of care?

"My grandchildren have moved in with us while their parents are going through financial difficulties." Many physical, emotional, social, and environmental factors can affect the client's health status and self-care behaviors. In this case, having the grandchildren move in due to financial hardships can be stressful, which would raise the client's blood pressure. Having new healthy cooking techniques, walking more (even if it is uphill and difficult), and home monitoring of blood pressure are all health-promoting activities, which should help to lower blood pressure.

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, which could potentially cause the client discomfort and harm.

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. 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.

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

Auscultating of bilateral lung sounds 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.

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. The nurse must take into consideration the client's developmental level and willingness to participate in care in order to successfully implement the plan of care. The client is a teenager and socialization with a peer group is essential, so the nurse would most appropriately wait until the visitors leave. Telling the visitors to leave in 10 minutes might upset the client and hinder the education. Simply asking if the client has questions does not appropriately educate the client. Leaving written information does not ensure that the client will read or understand the information.

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. The nurse must take into consideration the client's developmental level and willingness to participate in care in order to successfully implement the plan of care. The client is an adolescent and socialization with a peer group is essential, so the nurse would most appropriately wait until the visitors leave. Telling the visitors to leave in 10 minutes might upset the client and hinder the education. Simply asking if the client has questions does not appropriately educate the client. Leaving written information does not ensure that the client will read or understand the information.

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

Does this treatment make sense for this client? All of these questions are important, but the priority is whether the treatment makes sense for the client. If not, answering the other questions is unnecessary.

Which action is a nursing intervention that facilitates lifespan care?

Educate family members about normal growth and development patterns. Knowledge of normal growth and development is essential for family members to promote their own health and welfare throughout the lifespan, and to facilitate family functioning. Childbearing care includes interventions to assist in understanding and coping with psychological and physiologic changes during the childbearing period. Coping assistance includes interventions to assist the client in building on his or her strengths, to adapt to a change in function, or to achieve a higher level of function. Risk management includes interventions to initiate risk reduction activities.

A student nurse has reported for a clinical preceptorship in a hospital and has been reassigned from the medical surgical unit to a pediatric unit. The student nurse has never worked with pediatric clients. Which of the following actions should the student nurse take in this situation?

Inform the supervisor that she cannot accept this assignment because of a lack of experience with pediatric clients. The correct action in this situation is for the student nurse to inform the supervisor that she cannot accept the assignment since she is not competent working with pediatric clients. The student nurse cannot accept the assignment and only perform vital signs for the clients under her care. The student nurse cannot accept the assignment and then decide that she cannot competently care for the clients. Once the assignment has been accepted the student nurse has accepted responsibility for the clients until the end of her shift. This assignment is not an infraction of the nurse practice act. The student nurse has the option of not accepting the assignment.

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. 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.

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 An important nursing function is to enable clients to prevent illness. Because a member of the family has developed diabetes, the other family members are also at risk. The nurse would most appropriately educate the family about the risk factors for and prevention of diabetes mellitus. Knowledge of the medications used to treat diabetes is not necessary at this time and does not help meet the family's needs. The severity of the client's disease does not have an impact on the family's health. Knowledge of the cellular metabolism of glucose is not necessary for the family's health.

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 denies the need for education. The client is blind. The client's blindness will require the nurse to alter the education plan to fit the client's needs. The education might also require teaching another person to perform the wound care. If the client denies the need for education, attempting to teach the client at this time will be ineffective. The nurse will need to determine why the client denies the need for teaching and address that issue first. The facts that the client is male, married, and an architect do not have any bearing on the instruction.

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. 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 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. TJC encourages clients to become active, involved, and informed participants on the health care team. By becoming involved and "speaking up" research shows that clients who take part in decisions about their health care are more likely to have better outcomes. The nurse should never want to prevent client questions. While clients are encouraged to be independent, trusted family members and friends can be an asset to the client's care. The nurse should investigate the possibility of an error if the client questions the nurse about a medication.

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. A key component of the organizing interventions is to ensure adequate equipment (extra supplies) and sufficient personnel to assist with more complex tasks. Skills are first learned in nursing school but then validated with policies and procedures of the institution. Assistance is necessary to assist with the skill but is not the main issue in this scenario. Environment would be related to the lighting and space. Client issues would be the correct response if the client was cognitively aware and not confused. Logistics and planning may be related to other issues such as making sure all the elements such as personnel, client, environment, and assistance are all present.