Chapter 17: Implementing

The nurse is caring for a vegetarian who has iron deficiency anemia. The standardized nutritional plan for a client with anemia calls for the client to increase consumption of animal protein. How should the nurse plan to meet this client's nutritional needs? Collaborate with the nutritionist to modify the nutritional plan. Instruct the client that consumption of animal protein is necessary to cure the anemia. Meet with the client's family to emphasize the importance of nutritional modification. Arrange for animal protein to be disguised in the client's meal.

Collaborate with the nutritionist to modify the nutritional plan

Which are activities the nurse typically performs during the implementation step of the nursing process? Select all that apply. Collecting a database to enable an effective plan of care Developing client outcomes and goals Collecting additional client data Performing an initial assessment of the client Modifying the client plan of care Measuring how well the client has achieved client goals

Collecting additional client data Modifying the client plan of care

A client has terminal cancer and the primary care provider has ordered a diagnostic imaging test. The client does not want the test performed so the nurse agrees to dialogue with the primary care provider on the client's behalf. The nurse's actions are what type of intervention? Surveillance Supportive Coordinating Technical

Coordinating

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. Perform all care activities for the client to facilitate rest. Teach the family to anticipate the client's needs to care for the client. Arrange with the nurse case manager for an early discharge.

Encourage the client to provide as much self-care as possible.

The emergency room nurse is performing an initial assessment of a new client who presents with severe dizziness. The client reports a medical history of hypertension, gout, and migraine headaches. Which step should the nurse take first in the comprehensive assessment? Perform vital signs and blood glucose level. Discuss the need to change positions slowly, especially when moving from sitting to standing. Perform a full review of systems. Initiate an intravenous line and administer 500mL of normal saline.

Perform vital signs and blood glucose level

Before implementing any planned intervention, which action should the nurse take first? Have the required equipment ready for use. Reassess the client to determine whether the action is needed. Ask the client whether this is a good time to do the intervention. Record the planned intervention in the client's medical record.

Reassess the client to determine whether the action is needed

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? Supportive Maintenance Surveillance Collaborative

Surveillance

The client is having difficulty breathing. The respiratory rate is 44 and the oxygen saturation is 89% (0.89 L). The nurse raises the head of the bed and applies oxygen at 3 L/min per nasal cannula. How does the nurse determine the effectiveness of the interventions? Select 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 client is watching television. The client's family asks if the client is going to be okay.

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

Which examples of nursing actions involve direct care of the client? Select all that apply. A nurse counsels a young family who is interested in natural family planning. A nurse massages the back of a client while performing a skin assessment. A nurse arranges for a consultation for a client who has no health insurance. A nurse helps a client in hospice fill out a living will form. A nurse arranges for physical therapy for a client who had a stroke.

A nurse counsels a young family who is interested in natural family planning. A nurse massages the back of a client while performing a skin assessment. A nurse helps a client in hospice fill out a living will form.

Which nursing intervention 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 Changing a client's intravenous (IV) fluid from normal saline to 5% dextrose Administering a beta-adrenergic blocker to a new client whose blood pressure is high on admission assessment Changing a client's advance directive after the prognosis has significantly worsened

Administering a glycerin suppository to a constipated client who has not responded to oral stool softeners

The primary purpose of nursing implementation is to: help the client achieve optimal levels of health. implement the critical pathway for the client. improve the client's postoperative status. identify a need for collaborative consults.

help the client achieve optimal levels of health.

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

Discontinue the education and attempt at another time.

During morning report, the night nurse tells the oncoming nurse that the client has been medicated for pain and is resting comfortably. Thirty minutes later, the client calls and requests pain medication. What is the nurse's appropriate first action? Go to the client and assess the client's pain. Determine the frequency of pain medication. Medicate the client with the ordered pain medication. Instruct the client in nonpharmacologic pain management.

Go to the client and assess the client's pain

The emergency room (ER) has a strict protocol regarding intramuscular (IM) injection technique. A nurse working in the ER has learned of a new technique to decrease pain with IM injections from the nursing literature and would like to use it. What is the most appropriate way for the nurse to implement the technique? Begin using the technique to determine whether it is effective. Petition to change the protocol based on the new evidence. Ask the ER physician to order IM injections with the new technique. Research the protocols at other area emergency rooms.

Petition to change the protocol based on the new evidence

After learning about a client's limited financial resources and limited insurance benefits, the home care nurse modifies nursing interventions related to a client's care instructions. The nurse modifies the plan of care based upon which client variable? Psychosocial background Developmental stage Research findings Current standards of care

Psychosocial background

The registered nurse is working with an unlicensed assistive personnel. Which client should the nurse not delegate to the unlicensed assistive personnel? The client who needs vital signs taken following infusion of packed red blood cells. The client who requires assistance dressing in preparation for discharge. The client who is pleasantly confused and requires assistance to the bathroom. The client with continuous pulse oximetry who requires pharyngeal suctioning.

The client with continuous pulse oximetry who requires pharyngeal suctioning.

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. environment and client. logistics and planning. skills and assistance.

equipment and personnel.