Chapter 14 Concepts 1

A nurse is working with a community group to prevent the building of a toxic waste dump in the community. The nurse plans to lobby politicians. What type of nursing intervention is this?

Community

The nurse has administered pain medication to a client with a fractured femur. One hour later, the client reports relief of pain. What is the nurse's next action?

Document the effectiveness of the intervention.

The nurse is preparing a client with a bowel obstruction for emergency surgery. Of the following interventions, which has the highest priority?

Inform the client what to expect after the surgery.

Which is a responsibility of the nurse in the nurse-nurse team relationship?

Provide creative leadership to make the nursing unit a challenging place to work.

The nurse is attending a conference on evidence-based practice. Which statement by the nurse indicates further education is needed?

"I must conduct research to validate the usefulness of my nursing interventions."

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."

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?

"You should always speak up if you have any questions about your care."

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?

An asthma client who reports shortness of breath with a respiratory rate of 26 bpm

The nurse caring for a 5-year-old newly diagnosed with Type I diabetes mellitus is planning to give instruction to the client and the mother about insulin administration. When the nurse enters the room, the client is sleeping. How would the nurse best address the situation?

Ask the mother to call when the client is awake.

The surgeon is insisting that a client consent to a hysterectomy. The client says that she will not make a decision without her husband's consent. What is the nurse's best course of action?

Ask the surgeon to wait until the client has had a chance to talk to her husband.

One hour after receiving pain medication, a postoperative client complains of intense pain. What is the nurse's most appropriate first action?

Assess the client to determine the cause of the pain.

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.

The home health nurse caring for a client with limited eyesight notes that the client's route to the bathroom is cluttered. What is the most effective way for the nurse to ensure the client's safety?

Assist the client to identify strategies to promote safety in the home.

The nurse is caring for a vegetarian who is suffering from iron deficiency anemia. The nutritional plan for a client with anemia calls for the client to increase consumption of animal protein. How will the nurse plan to meet this client's nutritional needs?

Collaborate with the nutritionist to modify the nutritional plan.

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.

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 with your nursing instructor before performing the procedure.

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?

Coordinate with the case manager to make a safe discharge plan.

A client on the medical-surgical unit is scheduled for several diagnostic tests. The nurse is concerned that the tests will be too tiring for the client. What would be the nurse's most appropriate action?

Coordinate with the other disciplines to schedule the tests with adequate rest for the client.

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 alternatives to a blood transfusion with the physician.

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 primary purpose of nursing implementation is to

Help the client achieve optimal levels of health

A nurse is addressing a group of high school students. What would be the nurse's most appropriate statement to differentiate nursing from other health care disciplines?

Nurses focus on the client's reaction to health and illness.

The nursing supervisor visits the emergency department and informs the department manager that tornado victims are expected to arrive within the hour. The department manager indicates the department has been slow and requests information regarding possible numbers of victims. The department manager reports supplies were just fully stocked, but two nurses are ill with influenza and were unable to report for their shift. Which resource does the department manager need to organize to respond to the disaster?

Personnel

When the nurse enters the room to assess a client's vital signs, the client insists that the nurse perform hand washing. What is the nurse's most appropriate action?

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

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.

A client recovering after an appendectomy is complaining of pain. The nurse administers the ordered pain medication and assists the client to splint 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.

While withdrawing medications from the automated dispensing system, the nurse realizes that one of the medications in the bin is the wrong medication. The size and the color of the two medications are similar. What would be the most effective way for the nurse to address this dangerous situation?

Report the potential for client injury in the appropriate channels.

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.

The 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 is caring for a postoperative client who is receiving morphine sulfate for pain management. The nurse obtains the following vital signs. HR 74 RR 8 BP 114/68. After reviewing the nursing care plan and physician orders, the nurse administers naloxone (Narcan). What would allow the nurse to initiate this action?

Standing orders

An RN preceptor is orienting a new nurse to the unit. During the shift, one of the new nurse's clients dies. The new nurse becomes upset and is crying. What is the RN preceptor's most therapeutic first action?

Tell the new nurse that it is normal to be upset after the death of a client.

The nurse is planning instruction on wound care to an adult client. What variables would cause the nurse to alter the teaching plan? Mark all that apply.

The client denies the need for teaching. • The client is blind.

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 three years.

A student nurse is performing a sterile dressing change on a client's abdominal incision. While establishing her sterile field, the nurse drops her forceps on the floor. She is unable to continue with the dressing change because she has no extra supplies in the room, and no one is present to bring new forceps. The student has failed to organize ...

equipment and personnel.

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.

Nurses perform many independent nursing actions when caring for patients. Which action is considered an independent (nurse-initiated) action?

Helping to allay a patient's fears about surgery

The physician has ordered that the client should ambulate three times a day. The nurse enters the room to ambulate the client and the client complains of pain. What is the nurse's most appropriate action?

Medicate the client and wait to ambulate later.

The nurse is coordinating care for the client with continuous pulse oximetry who requires pharyngeal suctioning. Which staff member should the nurse avoid delegating the task of suctioning?

Nursing assistant who is a nursing student

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.

The client's respiratory rate decreases. • The client states, "I can breathe easier now." • The client's oxygen saturation level increases.

The Joint Commission encourages patients to become active, involved, and informed participants on the health care team. What nursing action follows TJC recommendations for improving patient safety by encouraging patients to speak up?

The nurse encourages the patient to participate in all treatment decisions as the center of the health care team.

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 the nurse does not have the experience to properly care for this client.

A 15-year-old girl tells the school nurse that her boyfriend is pressuring her to have sex. What is the nurse's most appropriate response?

Discuss the client's feelings about having sex.

A circulating nurse in the operating room observes the scrub nurse breaking sterile technique. What is the nurse's most appropriate action?

Inform the scrub nurse of the break immediately.

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.