Chapter 14

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? a) Discuss the risks and benefits of a blood transfusion with the client. b) Discuss possible alternatives to a blood transfusion with the physician. c) Discuss the client's options with other church members. d) Discuss the client's refusal with hospital risk managers.

B

The mother of a pediatric client 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? a) Arrange for a counseling session for the parents of the client. b) Advise the mother that she should report her concerns to the police. c) Coordinate with the case manager to make a safe discharge plan. d) Give the mother telephone numbers of women's shelters.

C

The client tells the nurse, "I think the nurse last night may have given me the wrong medication, but I was afraid to say anything." What is the nurse's most appropriate response? a) "I will report your concerns to the nurse manager." b) "You always have the right to refuse any medication or treatment." c) "I will discuss your concerns with the night nurse." d) "You should always speak up if you have any questions about your care."

D

Nurses implement care for patients in various health care settings. Which activities would typically be carried out during the implementation step of the nursing process? (Select all that apply.) a) Developing patient outcomes and goals b) Measuring how well the patient has achieved patient goals c) Performing an initial assessment of the patient d) Modifying the patient plan of care e) Collecting a database to enable an effective plan of care f) Collecting additional patient data

DF

implementing

nursing actions planned in the previous step that are carried out

indirect care intervention

tx performed away from patient but on behalf of patient e.g. management of patient care environment interdisciplinary collaboration

direct care intervention

tx performed through interaction w/ patient e.g. the "laying of hands" actions (physiological) supportive/counseling nature (psychosocial)

protocols

written plans that detail nursing activities to be executed in specific situations

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? a) Refer the client to available community resources and support groups. b) Ask the client to verbalize the medication regimen and diet modifications required. c) Ask the nutritionist to give the client strict meal plans to follow. d) Ask the gastroenterologist to explain the treatment plan to the client and family again.

B

A student nurse received a report on his assigned clients for the clinical day. Which of the following clients should the student nurse plan to assess first? a) A client who has had a hysterectomy and reports bleeding from the surgical site b) An asthma client who reports shortness of breath with a respiratory rate of 26 bpm c) A newly diagnosed diabetic who is crying and states "I do not understand how to give my insulin." d) A client who has had an appendectomy and has a temperature of 102.4°F

B

The client is having difficulty breathing. The respiratory rate is 44 and the oxygen saturation is 89%. The nurse raises the head of the bed and applies oxygen at 3L/min per nasal cannula. How does the nurse determine the effectiveness of the interventions? Mark all that apply. a) The client is watching television. b) The client's oxygen saturation level increases. c) The client's respiratory rate decreases. d) The client states, "I can breathe easier now." e) The client's family asks if the client is going to be okay.

BCD

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? a) "Moving away from client care is a necessary step to advancing my career." b) "Even though I do not provide direct care to clients, my work is very important." c) "I provide indirect care to my clients by coordinating their treatment with other disciplines." d) "I provide a critical service that is necessary for financial reimbursement."

C

implementing guidelines

act in partnership w/ pt/family reassess to see if action still needed communicate w/ concern; words pt understands are interventions consistent w/I practice/ legal more options; greater likelihood of success evaluate effectiveness consult health care colleagues; literature

activities in implementing

carrying out the plan continuing data collection modifying plan of care as needed document care

implementing guidelines: modify nursing interventions according to

developemental & psychosocial background ability and willingness to participate responses to previous nursing measures &progress

standing orders

empower the nurse to initiate actions that ordinarily require the order or supervision of a physician e.g bowel programs OD narcotics (narcan) pain management (select strength w/I preset range)

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

A

When the nurse is administering medication, an elderly client states, "Why does everyone keep asking my name? I've been here for days." How should the nurse respond to the client? a) "We ask your name to ensure that we are treating the right client." b) "It is a hospital policy to reduce the potential for errors." c) "We ask your name to show that we respect your rights." d) "It is a habit that nurses develop in school."

A

Nurses utilize the McCloskey, Dochterman, and Bulechek Nursing Interventions Classification (NIC) report of research when choosing nursing interventions for patients. What are advantages of having standard Nursing Interventions Classifications (NIC)? (Select all that apply.) a) Teaching decision making b) Allowing the use of multiple systems of nomenclature c) Communicating nursing to non-nurses d) Allocating nursing resources e) Limiting the amount of reimbursement allowed for nursing services f) Developing information systems

ABCF

Which nursing actions reflect the implementing step of nursing process? Select all that apply. a) Referring the client to community resources, when necessary b) Providing health education to reduce health risks c) Determining the client's response to nursing interventions d) Selecting culturally sensitive nursing interventions e) Using evidence-based interventions individualized for the client

ABE