Chapter 17: Implementing

Which is the nurse's priority question to consider prior to delegating a task to an unlicensed assistive personnel (UAP)? 1. How can I supervise the completion of this task? 2. Does this task fall within the scope of a UAP? 3. What is the client's condition? 4. How can I explain the task to the UAP?

2. Does this task fall within the scope of a UAP?

Which are benefits of using the nursing intervention classification (NIC) system for the development of interventions? Select all that apply. Justification of the productivity of the nursing staff Creation of a standardized language Demonstration of the impact of nurses Determination of which nursing actions the nurse may delegate Assistance in determining the cost of services that nurses provide

Creation of a standardized language Assistance in determining the cost of services that nurses provide Demonstration of the impact of nurses

One hour after receiving pain medication, a postoperative client reports intense pain. What is the nurse's appropriate first action? a) Assess the client to determine the cause of the pain. b) Consult with the physician for additional pain medication. c) Discuss the frequency of pain medication administration with the client. d) Assist the client to reposition and splint the incision.

a) Assess the client to determine the cause of the pain.

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? 1. Tell the client that gloves are required for this procedure. 2. Praise the client for taking an active role in the client's care. 3. Inform the client that it is not necessary to wash hands before vital signs. 4. Reassure the client that the nurse knows when to perform hand hygiene.

2. Praise the client for taking an active role in the client's care.

Which is an independent (nurse-initiated) action? 1. Administering medication to a client 2. Meeting with other health care professionals to discuss a client 3. Helping to allay a client's fears about surgery 4. Executing physician orders for a catheter

3. Helping to allay a client's fears about surgery

An 87-year-old client has been admitted to the hospital several times in the past few months for exacerbations of chronic obstructive pulmonary disease and elevated blood glucose levels. Which statement by the client could help identify the most likely reason for the changes in the client's health status? a) "My daughter has been staying with me the past few weeks." b) "I sort my medication into an organizer every week." c) "I asked my neighbors to help me with my yard work." d) "My wife's been gone for about 7 months now."

d) "My wife's been gone for about 7 months now."

Before implementing any planned intervention, which action should the nurse take first? 1) Ask the client whether this is a good time to do the intervention. 2) Reassess the client to determine whether the action is needed. 3) Have the required equipment ready for use. 4) Record the planned intervention in the client's medical record.

2) Reassess the client to determine whether the action is needed.

Which action should the nurse take to ensure that an unlicensed assistive personnel (UAP) understands the instructions to perform a delegated task? 1) Instruct the UAP to repeat the instructions to be sure the nurse has communicated clearly. 2) Inform the UAP of the importance of following each step listed in the procedure manual. 3) Request that the UAP place the steps of the task in the framework of the nursing process. 4) Ask another UAP to observe and assist the UAP in performing the task.

1) Instruct the UAP to repeat the instructions to be sure the nurse has communicated clearly.

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? 1. Ask the client to verbalize the medication regimen and diet modifications required. 2. Refer the client to available community resources and support groups. 3. Ask the nutritionist to give the client strict meal plans to follow. 4. Ask the gastroenterologist to explain the treatment plan to the client and family again.

1. Ask the client to verbalize the medication regimen and diet modifications required.

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? 1. Coordinate with the other disciplines to schedule the tests with adequate rest for the client. 2. Instruct the client to refuse the diagnostic tests if the client becomes too fatigued. 3. Coordinate with the other disciplines to determine if all the tests scheduled are necessary. 4. Review the physician's progress notes to determine if any of the tests are not indicated.

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

The nurse is preparing a client with a bowel obstruction for emergency surgery. Which intervention has the highest priority for this client? 1. Inform the client what to expect after the surgery. 2. Discuss discharge plans with the client. 3. Instruct the client and family in wound care. 4. Teach the client about dietary restrictions during recovery.

1. Inform the client what to expect after the surgery.

While auscultating a client's lung sounds, the nurse notes crackles in the left lower lobe, which were not present at the start of the shift. The nurse is engaged in which type of nursing intervention? Educational Psychomotor Maintenance Surveillance

Surveillance

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? a) The parents verbalize acceptance of the need to closely monitor their child's condition. b) The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years. c) The client expresses a desire to learn how to manage the medication regime. d) The parents have comprehensive insurance coverage for their family's medical care.

b) The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years.

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? a) Initiate an intravenous line and administer 500 mL of normal saline. b) Perform a full review of systems. c) Discuss the need to change positions slowly, especially when moving from sitting to standing. d) Perform vital signs and blood glucose level.

d) Perform vital signs and blood glucose level.

Which task would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? 1. Provide the client with assistance in transferring to the bedside commode. 2. Reassess the client's sacrum for redness when doing a bed bath. 3. Retrieve a unit of blood from the blood bank. 4. Assess an IV site for possible infiltration

1. Provide the client with assistance in transferring to the bedside commode.

The nurse in a burn intensive care unit (BICU) is caring for a 3-year-old child who was burned with scalding hot water. The client has burns covering 75% of the body. The client's condition is critical but stable. At 1000, the nurse reassesses the client and finds that the client is agitated and pulling at the endotracheal tube. Which is the nurse's priority intervention for this client at this time? 1. Providing medication for agitation 2. Ensuring that the endotracheal tube is secure 3. Repositioning to prevent pressure injuries 4. Changing the dressing to prevent infection

2. Ensuring that the endotracheal tube is secure

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? 1. Discontinue the education and ask the client for permission to teach a family member. 2. Medicate the client for anxiety and continue the education later. 3. Discontinue the education and attempt at another time. 4. Continue the education and remind the client that it is essential to learn self-care.

3. Discontinue the education and attempt at another time.

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? Registered nurse Licensed practical nurse A senior nursing student present for clinical Nursing assistant

Nursing assistant

The physician has ordered that the client should ambulate 3 times a day. The nurse enters the room to ambulate the client and the client reports pain. What is the nurse's most appropriate action? a) Emphasize to the client the importance of following the treatment plan. b) Ambulate the client and medicate later. c) Explain to the client the benefits of ambulation. d) Medicate the client and wait to ambulate later.

d) Medicate the client and wait to ambulate later.