Chapter 17: Implementing PrepU

A client is admitted to the mental health center after attempting suicide. Which client concern is the priority for the nurse to manage? a. Risk of self-harm b. Lack of support c. Low self-esteem d. Feelings of not belonging

a. Risk of self-harm Safety and security are the priority for the client, so the risk of self-harm is what the nurse must address first. Lack of support, low self-esteem, and feelings of not belonging, although still important to address, are not as critical as safety and security.

The nurse is discussing dietary options with a client who is upset due to not being able to have foods the client previously enjoyed. The nurse states, "You may not be able to have steak, but you can have grilled salmon or grilled chicken. Which do you prefer?" What is the purpose for giving the client an option? a. To help the client adhere to the plan b. To give the client the opportunity to actively participate in care c. To save the client the trouble of looking in the menu d. To encourage the client to make a healthy food choice

b. To give the client the opportunity to actively participate in care Giving clients options allows them to actively participate in their own care, which is empowering. Although giving the client options might improve the client's adherence to the plan, this is not the primary purpose. The purpose of giving the client options is not to save the client the trouble of looking in the menu or to encourage the client to make a healthy food choice.

Priority setting is based on the information obtained during reassessment and is used to rank nursing diagnoses. Each factor contributes to priority setting except which? a. Finances of the client b. The client's condition c. Time and resources d. Feedback from the family

a. Finances of the client The client's condition, time and resources, and feedback or input from the family are all of great value when the nurse is prioritizing the client's nursing diagnoses. The client's finances, however, should not influence the nurse's priority setting. The nursing code of ethics states that clients should receive the same treatment regardless of their ability to pay.

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? a. Registered nurse b. Nursing assistant c. A senior nursing student present for clinical d. Licensed practical nurse

b. 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.

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

b. Inform the client what to expect after the surgery. If the surgery is an emergency, the highest priority is to meet the client's immediate needs. The nurse should inform the client about what to expect after surgery. Discussing discharge plans, instructing in wound care, and teaching about dietary restrictions are important, but not necessary before the surgery.

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? a. Surveillance b. Supportive c. Coordinating d. Technical

c. Coordinating Coordination involves acting as a client advocate, making referrals for follow-up care, collaborating with other health care team members, and ensuring that the client's schedule is therapeutic. This is not a surveillance or technical type of intervention. The nurse is being supportive of the client, but advocacy is more closely associated with coordinating types of interventions.

Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? a. Bed bath for the newly admitted client who has multiple skin lesions b. Preparation of insulin for the diabetic client with an elevated blood glucose level c. Ambulation of the client with a history of falls for the first time after surgery d. Insertion of a urinary catheter in a client with benign prostatic hypertrophy

a. Bed bath for the newly admitted client who has multiple skin lesions The safest delegation is to have the UAP bathe the client with skin lesions and report any abnormal findings to the nurse. Preparing insulin is outside of the UAP's scope of practice. The UAP may have the skills to insert an indwelling catheter and ambulate clients, but the clients involved each have qualifiers that complicate the tasks.

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? a. Medications used to treat diabetes mellitus b. Risk factors for and prevention of diabetes mellitus c. The severity of the client's disease d. The cellular metabolism of glucose

b. 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.

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? a. Educational b. Psychomotor c. Maintenance d. Surveillance

d. Surveillance Surveillance interventions include detecting changes from baseline data and recognizing abnormal response. 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. Educational interventions require instruction, demonstration, and return demonstration of knowledge or a skill set. Psychomotor interventions involve the nurse physically working with the client. Maintenance interventions involve the nurse assisting the client with performing routine activities of daily living.

The nursing is caring for several clients. Which intervention can the nurse direct the unlicensed assistive personnel (UAP) to perform? a. Take the vital signs of the client who just returned from surgery. b. Feed a client who is eating for the first time following an ischemic stroke. c. Bathe a client with stable angina who has a continuous IV infusing. d. Assist the client who is ambulating the first time since hip replacement surgery.

c. Bathe a client with stable angina who has a continuous IV infusing. The nurse can instruct the UAP to bathe the client with stable angina who has a continuous IV infusing. The other clients require the clinical reasoning skills of the nurse to evaluate their response.

A nurse is caring for a client with burns. Place the steps in the appropriate order for providing wound care for the client. Use all options. a. Record color and odor of discharge. b. Change from clean to sterile gloves. c. Open sterile dressing tray. d. Remove old dressing. e. Obtain a culture. f. Assess condition of wound.

d. Remove old dressing. f. Assess condition of wound. e. Obtain a culture. c. Open sterile dressing tray. b. Change from clean to sterile gloves. a. Record color and odor of discharge. The nursing care plan begins with assessment. After removing the old dressing, the nurse should perform the initial assessment of the wound first and then take a swab stick sample for culture (implementation). Next, the nurse changes the dressing (implementation) of the wound, by first opening the dressing tray and changing from clean to sterile gloves to prevent contamination of the wound. Finally, the nurse documents the findings (documentation). Documentation should occur after the assessment and implementation of care has occurred.

The nurse is attending a conference on evidence-based practice. Which statement by the nurse indicates further education is needed? a. "I must conduct research to validate the usefulness of my nursing interventions." b. "I can learn about evidence-based practice by reading professional nursing journals." c. "Nursing interventions should be supported by a sound scientific rationale." d. "The Agency for Healthcare Research and Quality is a resource for evidence-based practice."

a. "I must conduct research to validate the usefulness of my nursing interventions." Nursing interventions should be supported by a sound scientific rationale; however, nurses do not need to personally conduct research to establish the rationale for nursing interventions. Nurses can learn about evidence-based practice by reading professional nursing journals, attending nursing workshops, and consulting evidence-based practice resources, such as the Agency for Healthcare Research and Quality.

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

a. A nurse counsels a young family who is interested in natural family planning. b. A nurse massages the back of a client while performing a skin assessment. d. A nurse helps a client in hospice fill out a living will form. A direct care intervention is a treatment performed through interaction with the client(s). Direct care interventions include both physiologic and psychosocial nursing actions, and include both the "laying of hands" actions and those that are more supportive and counseling in nature. An indirect care intervention is a treatment performed away from the client but on behalf of a client or group of clients. Indirect care interventions include nursing actions aimed at management of the client care environment and interdisciplinary collaboration.

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. 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.

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? a. Assess the client's blood pressure to determine if the medication is indicated. b. Determine the client's reaction to the medication in the past. c. Ask the client to verbalize the purpose of the medication. d. Tell the client to report any side effects experienced.

a. Assess the client's blood pressure to determine if the medication is indicated. Before initiating any intervention, the nurse must determine if the intervention is still necessary. Before administering blood pressure medication, the blood pressure must be assessed. The client's reaction to the medication previously does not indicate if the medication is indicated at this time. The client's ability to verbalize the purpose of the medication is important to promote self-care, but it is not important for the client's safety at this time. The client's report of side effects would indicate an adverse reaction after the medication is administered, but it would not protect the client's safety before the medication is given.

Which nursing action can be categorized as a surveillance or monitoring intervention? a. Auscultating of bilateral lung sounds b. Providing hygiene c. Administering a paracetamol tablet d. Use of therapeutic communication skills

a. 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.

A client being treated for myasthenia gravis at home tells the nurse, "This medicine is so expensive. I have only been taking half of what the doctor ordered." How would the nurse most effectively meet this client's need? a. Collaborate with other disciplines to determine the best way to meet the client's medication requirements. b. Reinforce to the client and family the necessity of taking all medication as ordered to stabilize the client's condition. c. Inform the physician of the need to prescribe a less expensive medication for the client's condition. d. Instruct the client that some pharmaceutical companies have programs to help with medication expenses.

a. Collaborate with other disciplines to determine the best way to meet the client's medication requirements. In order to meet the client's needs, it is most important to involve other disciplines in the client's care to utilize all available resources. Reinforcing the importance of the medication does not solve the financial problem. It may be necessary for the physician to prescribe a less expensive medication, but other options should be considered to address the holistic needs of the client. Some pharmaceutical companies have programs to help with medication expenses, but the client will need information in order to apply for the programs.

Discharge plans for a client with a mental health disorder include living with family members. The nurse learns that the family is no longer willing to allow the client to live with them. What is the nurse's most appropriate action? a. Collaborate with other disciplines to revise the discharge plans. b. Instruct the client to make alternate living arrangements. c. Communicate with the physician about additional orders. d. Inform the family that it is not possible to change the discharge plans.

a. Collaborate with other disciplines to revise the discharge plans. The discharge needs of this client are complicated, and the nurse will need the assistance of other disciplines to make a successful discharge plan. The client should have input into the future living arrangements, but the client does not have the resources to make the arrangements alone. The physician may be involved in the discharge plan, but additional orders are not necessary. It is not true (and would be inappropriate) to tell the family that discharge plans cannot be changed. If the family is unwilling to take the client, the placement will be unsuccessful.

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? a. Collaborate with the nutritionist to modify the nutritional plan. b. Instruct the client that consumption of animal protein is necessary to cure the anemia. c. Meet with the client's family to emphasize the importance of nutritional modification. d. Arrange for animal protein to be disguised in the client's meal.

a. Collaborate with the nutritionist to modify the nutritional plan. A vegetarian does not consume animal proteins. Although animal proteins are an important source of iron, plant proteins are available. To honor the preferences of the client, the nurse would collaborate with the nutritionist to include these plant sources of protein in the client's diet (instead of the animal protein). It is not true that the client has to consume animal protein to cure the anemia. Meeting with the client's family would be inappropriate because this would violate the wishes of the client. Arranging for animal protein to be disguised in the client's meal would violate the client's trust and would also not be effective in the long term after the client has been discharged.

A nurse is preparing to educate a client about self-care after cataract surgery. Which should the nurse do first? a. Determine the client's willingness to follow the regimen. b. Identify changes from the baseline. c. Ensure physician approval for the education plan. d. Instruct the unlicensed assistive personnel on what to teach the client.

a. Determine the client's willingness to follow the regimen. The prerequisite to health education about self-care after cataract surgery is the client's willingness to follow the regimen. Once a nurse is aware of the client's readiness for learning, the nurse can implement outcome-based education plans. Identifying changes from baseline is important for monitoring interventions. Approval by the physician may not be necessary. Delegating the teaching activity to an unlicensed assistive personnel is inappropriate because it is not within the person's scope of practice.

Which action is a nursing intervention that facilitates lifespan care? a. Educate family members about normal growth and development patterns. b. Explore factors that could motivate adolescent members of the family to engage in risky behaviors. c. Identify coping strategies for the family that have worked in the past. d. Teach contraceptive options for planned pregnancy.

a. 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.

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? a. Encourage the client to provide as much self-care as possible. b. Perform all care activities for the client to facilitate rest. c. Teach the family to anticipate the client's needs to care for the client. d. Arrange with the nurse case manager for an early discharge.

a. Encourage the client to provide as much self-care as possible. The nurse must encourage the client to provide as much self-care as possible in order to achieve the highest level of independence. Performing all care activities for the client makes the client dependent on the nurse. If the family anticipates and meets all the client's needs, this also hinders the client's recovery. An early discharge is not indicated because the client must be sufficiently recovered.

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? a. Go to the client and assess the client's pain. b. Determine the frequency of pain medication. c. Medicate the client with the ordered pain medication. d. Instruct the client in nonpharmacologic pain management.

a. Go to the client and assess the client's pain. The nurse's first action should always be to determine the cause of the client's pain in order to determine the correct intervention. After determining the cause, the nurse can plan how to proceed. The other steps would be appropriate, but only after the assessment.

The nurse ascertains that a client is failing to follow the plan of care that was collaboratively developed. Further investigation determines that the plan of care is not appropriate for this client. What is the nurse's next step in correcting this problem? a. Make changes in the plan of care based upon assessment data. b. Ask the client's family to assist the client in following the plan of care. c. Provide information to the client on the benefits of complying with the plan of care. d. Discuss the desired outcomes with the client and the importance of the outcomes.

a. Make changes in the plan of care based upon assessment data. A plan of care that is inappropriate for the client requires a change in the plan of care, not a change in the client. In situations when the plan of care is appropriate, the nurse must evaluate factors that contribute to the client's failure to comply. Such factors include lack of family support, lack of understanding of the benefits of compliance, low value attached to the outcomes and related interventions, and adverse or emotional effects of treatment.

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

a. Perform vital signs and blood glucose level. A patient who presents with severe dizziness needs a comprehensive assessment, including vital signs and blood glucose level, prior to any other action. The results of the assessment could help determine which actions to take next. Discussing the need to change positions slowly and home blood pressure monitoring may be appropriate educational activities for this client, but the assessment should be performed first to be sure that the client's symptoms are caused by hypotension. The client may also need intravenous fluids to help correct hypotension, but the client must be assessed first.

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? a. Psychosocial background b. Developmental stage c. Research findings d. Current standards of care

a. Psychosocial background The nurse is demonstrating an awareness of the client's psychosocial background, which includes consideration of the client's socioeconomic status. Research findings and current standards of care are examples of nursing variables. Developmental stage is a client variable that addresses the developmental needs of a client.

A nurse in the intensive care unit (ICU) has been assigned to care for a client who was seriously injured during a gang rape. The nurse was raped 6 months ago and fears being too upset to care for the client properly. How should the nurse deal with the assignment? a. Recognize the nurse's own limitations and ask for another nurse to be assigned. b. Recognize that the nurse may be faced with this issue again and care for the client. c. Recognize the nurse's own limitations and ask another nurse to assist if the nurse becomes too emotional. d. Recognize the issue and care for the client to the best of the nurse's ability.

a. Recognize the nurse's own limitations and ask for another nurse to be assigned. The nurse should keep the client's best interests in mind. If the nurse feels that the nurse's emotional state would compromise the client's care, the best course would be for the nurse to request a different assignment. The other courses of action leave the possibility that the client's care could be compromised.

A client with hypertension being seen for follow-up care has a blood pressure of 160/100 mm Hg. The client reports following the treatment regimen closely and that blood pressure readings have been elevated for the last 2 weeks. What is the nurse's most appropriate action? a. Report the findings to the physician for further plans. b. Reinforce the instructions for the treatment regimen to the client. c. Interview the family to determine if the client is giving accurate information. d. Inform the client that the blood pressure medication will have to be changed.

a. Report the findings to the physician for further plans. The nurse should report the findings to the physician so that the treatment regimen can be revised. The client reports following the treatment regimen, so reinforcing the instructions is not indicated. Interviewing the family would indicate to the client that the nurse did not trust the client's report, so this would be inappropriate. The nurse cannot tell the client that the blood pressure medication will have to be changed because that is the physician's decision.

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? a. Revise the care plan to allow the client to ambulate to the bathroom independently. b. Continue assisting the client to the bathroom to ensure the client's safety. c. Consult with the physical therapist to determine the client's ability. d. Instruct the client's family to assist the client to ambulate to the bathroom.

a. Revise the care plan to allow the client to ambulate to the bathroom independently. The intervention of assisting the client to the bathroom is no longer indicated, so the nurse would appropriately revise the care plan to discontinue that intervention. A consult with a physical therapist is not necessary to verify the nurse's independent assessment. If the client is safe to ambulate to the restroom independently, it is not necessary for the family to assist.

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

a. The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years. If the family has experience caring for a child with a seizure disorder, the family would already have some basic knowledge, so the nurse would address the education differently. The client expressing a desire to learn indicates receptiveness to the education. The parents' acceptance of their child's condition indicates that they are ready to begin dealing with the child's condition. The fact that the child has comprehensive insurance coverage is a strength that will make options available to the family, but will not necessarily change the nurse's educational plan

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. a. The client's respiratory rate decreases. b. The client states, "I can breathe easier now." c. The client's oxygen saturation level increases. d. The client is watching television. e. The client's family asks if the client is going to be okay.

a. The client's respiratory rate decreases. b. The client states, "I can breathe easier now." c. The client's oxygen saturation level increases. When reassessing the client after implementing interventions to increase oxygenation, the nurse would look for a decrease in respiratory rate to a more normal rate and an increase in the oxygen saturation level. The client's subjective statement of breathing easier would also indicate effectiveness. The client watching television and the client's family's statement do not indicate anything about oxygenation status.

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: a. equipment and personnel. b. environment and client. c. logistics and planning. d. skills and assistance.

a. 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.

A client with diabetes who has been closely following the prescribed plan of care for over a year is being seen at an outpatient facility. The client has not brought a log of daily glucose checks and tells the nurse, "I haven't been doing them regularly." What is the nurse's most therapeutic statement to the client? a. "It is extremely important to your health to strictly follow your plan of care." b. "It seems like you are having difficulty with your care regimen." c. "Should I arrange for a home health nurse to coordinate your care?" d. "Should I instruct your family to do the glucose checks for you?"

b. "It seems like you are having difficulty with your care regimen." The nurse's open-ended statement acknowledging that the client is having difficulty with the care regimen encourages the client to discuss what has occurred that has caused the client to not manage the diabetes as was previously done. The statement reminding the client that health care is important will discourage the client to freely discuss any problems. A home health nurse or instructions given to the family may be indicated, but not until the client has verbalized the reasons why the care regimen has not been followed.

An unlicensed assistive personnel (UAP) has worked on the postpartum unit for many years. The UAP has been oriented well and provides excellent client care. What duties could the professional nurse appropriately delegate to the UAP? Select all that apply. a. Initial assessment of the mother after birth of the infant b. Assisting the client with personal hygiene needs and ambulation c. Assisting and teaching the client to breastfeed the infant d. Providing routine discharge instructions related to infant care e. Transporting the infant to the mother's room according to hospital policy

b. Assisting the client with personal hygiene needs and ambulation e. Transporting the infant to the mother's room according to hospital policy It is essential when delegating duties that the registered nurse (RN) is aware the nurse's role and what duties can be delegated. The nurse also must be aware of the training and the competence of the UAP. The nurse could appropriately delegate assisting with personal hygiene needs, ambulation, and transporting the infant to the mother's room according to hospital policy. Assessment is the role of the RN and cannot be delegated. Teaching, including breastfeeding education and discharge instructions, is also the role of the RN and cannot be delegated.

A nurse is catheterizing a client. Which scenario demonstrates steps the nurse would take to ensure client respect and privacy? a. Verify the client's identifiable information, explain the procedure to the family, and pull the privacy curtain to allow the client to feel comfortable in having family close by. b. Close the door to the room, explain the procedure to the client, and cover all areas of the client, only exposing the area for catheterization. c. Ask family members to leave the room briefly, close the door, and ask the client if he or she would like a sheet to cover oneself. d. Bring in another nurse to provide support and prevent questionable behaviors, explain the procedure to the client, and close the door and privacy curtain prior to beginning the procedure.

b. Close the door to the room, explain the procedure to the client, and cover all areas of the client, only exposing the area for catheterization. It is important to think about the environment for each intervention. Pay special attention to respecting the client's privacy and dignity; for example, close the door to the room or pull the drapes between the beds. To demonstrate respect, the procedure should be explained to the client and all areas except the sterile area should be covered to protect modesty and privacy. Asking another nurse to assist is helpful, but not required and may make the client feel awkward. There is no need to discuss with the family, because the client does not have any cognitive issues.

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. 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.

A client is diagnosed with hypertension, placed on a low-sodium diet, and given smoking cessation literature. The nurse observes the client eating from a fast food restaurant bag that a family member brought in and the client states, "I don't think I can do this." What is the nurse's first objective when implementing care for this client? a. Explain the effects of a high-salt diet and smoking on blood pressure. b. Identify what barriers the client feels are preventing adherence with the plan. c. Collaborate with other health care professionals about the client's treatment. d. Change the nursing care plan.

b. Identify what barriers the client feels are preventing adherence with the plan. The nurse must first identify why the client is not following the therapy before collaboration with other health care professionals or a change in the nursing care plan can be initiated. Simply explaining the effects of a high-salt diet and smoking on the blood pressure may not address the underlying cause of why the client is choosing not to follow the recommended care.

The nurse is coordinating care for a client with continuous pulse oximetry who requires pharyngeal suctioning. To which staff member should the nurse avoid delegating the task of suctioning? a. Registered nurse b. Nursing assistant who is a nursing student c. A senior nursing student present for clinical d. Licensed practical nurse

b. Nursing assistant who is a nursing student The nurse should avoid delegating this client to the nursing assistant who is a nursing student. Suctioning and the associated evaluation of the client would be within the scope of practice of the registered nurse, licensed practical nurse, and the senior nursing student present for clinical.

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? a. Teach the content again utilizing the same method. b. Reassess the appropriateness of the method of instruction. c. Revise the plan to include the inclusion of a support group. d. Report the client's inability to learn to the case manager.

b. 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.

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

b. Reassess the client to determine whether the action is needed. Although being prepared with the necessary equipment and checking with the client to make sure that the client is physically and psychologically ready for the intervention are important, it is crucial to reassess the client to determine whether the action is still needed before implementing any nursing intervention. Recording the intervention occurs after the nurse has completed the intervention.

The registered nurse (RN) is delegating the task of assisting a postoperative client to the bathroom to the unlicensed assistive personnel (UAP). The nurse witnessed the UAP correctly perform the task on previous occasions and knows the UAP is competent to perform the task. The nurse has communicated how to get the client out and back into bed and told the UAP not to allow the client to bear weight on the left leg. The nurse validated that the activity was completed and gave the UAP feedback. Which delegation guideline did the nurse omit? a. Right task b. Right circumstance c. Right person d. Right supervision

b. Right circumstance The nurse fails to follow the delegation guideline related to right circumstance. The RN did not assess the client's needs or identify the outcome to be achieved by the task that was delegated. The other guidelines were followed.

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? a. Supportive b. Surveillance c. Collaborative d. Maintenance

b. 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.

The client has a diagnosis of Risk for Injury related to falls. How would the nurse know if the intervention was successful? a. The client calls for assistance to get out of bed. b. The client is free of falls. c. The client is taught safety precautions. d. The client verbalizes risks for injury.

b. The client is free of falls. Interventions for risk diagnoses are directed at prevention. The most appropriate way to evaluate the success of the interventions is to determine if the risk was prevented. The best evaluation criteria would be if the client remained free of falls. The client calling for assistance might prevent a fall, but does not signify that a fall will not occur. Teaching clients safety precautions and having the client verbalize risk for injuries is important but does not necessarily mean that an injury is prevented.

When caring for a client in the emergency room who has presented with symptoms of a myocardial infarction (MI), the nurse orders laboratory tests and administers medication to the client before the physician has examined the client. For the nurse to be operating within the nurse's scope of practice, what conditions must be present? a. The nurse is using the standards of care for clients with MIs. b. The nurse is operating under standing orders for clients with suspected MIs. c. The nurse is experienced in the needs of clients with MIs. d. The nurse is ordering what the physician usually orders.

b. The nurse is operating under standing orders for clients with suspected MIs. For the nurse to administer medications or order laboratory tests, the nurse must have a physician's order. In special circumstances, such as in the emergency room, there are standing orders in place to authorize the nurse's actions in certain situations. The other three statements may also be true, but they do not give the nurse the authority to institute these actions independent of a physician's order.

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

c. "We ask your name to ensure that we are treating the right client." The primary reason for asking the client to state the client's name is to ensure that the nurse is dealing with the correct client. Asking the client to state the client's name is a habit that should be developed in nursing school, but that is not the reason nurses ask clients for their names. It is not just a hospital-specific policy to ask the client for the client's name, but it is a step that is used in all client care situations. Respecting clients' rights is important but that is not why nurses ask for their names.

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. "I will discuss your concerns with the night nurse." c. "You should always speak up if you have any questions about your care." d. "You always have the right to refuse any medication or treatment."

c. "You should always speak up if you have any questions about your care." The priority is to empower the client into taking an active role in the client's care, so the nurse should tell the client to feel free to ask questions. The client does have the right to refuse, but this does not address the issue. Speaking to the nurse manager or the night nurse does not help the client deal with a similar situation in the future.

A client requires a change and reapplication of a colostomy bag. The nurse has never changed an ostomy bag before. What is the nurse's best course of action? a. Ask the client how the bag is changed. b. Read the policy and procedure manual. c. Ask a skilled nurse to assist with the procedure. d. Determine the necessity of the bag change.

c. Ask a skilled nurse to assist with the procedure. Professional nurses should only undertake tasks that they have been properly trained to perform. Because the nurse has no experience in changing an ostomy bag, it would be most appropriate to have the assistance of an experienced nurse. It would be inappropriate to ask the client how the bag is changed. The client is relying on the nurse to have the necessary technical knowledge. Reading the policy and procedure manual alone would not ensure the successful completion of the procedure. The necessity of the ostomy bag change has already been established.

The surgeon is insisting that a client consent to a hysterectomy. The client refuses to make a decision without the consent of the client's spouse. What is the nurse's best course of action? a. Remind the client that the client is responsible for the client's own health care decisions. b. Ask the client whether the client is afraid that the spouse will be angry. c. Ask the surgeon to wait until the client has had a chance to talk to the spouse. d. Inform the surgeon that the nurse will not sign the informed consent form.

c. Ask the surgeon to wait until the client has had a chance to talk to the spouse. It is important to consider the client's wishes, so the nurse should advocate for the client and ask the surgeon to wait until the client has talked to the spouse. Telling the client that the client is responsible for the client's own health care decisions does not respect the client's desire to consult the spouse. The client has not expressed being fearful of the spouse. Informing the surgeon that the nurse will not sign the consent form will not satisfy the client's request.

After instituting interventions to increase oxygenation, the client shows no signs of improvement. What is the nurse's priority action? a. Document the interventions and the result. b. Reassess the client for improvement in 30 minutes. c. Communicate with the physician for additional orders. d. Determine the client's code status in case of an emergency.

c. Communicate with the physician for additional orders. If the nurse's interventions have been ineffective, the physician must be notified of the client's deteriorating status. The physician can direct other medical interventions. Documenting the interventions does not take priority over the client's physiologic needs. Allowing another 30 minutes to elapse before taking action will only cause further deterioration in the client's status. The nurse should know the client's code status when taking over the client's care.

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

c. Discontinue the education and attempt at another time. The nurse should always perform client education when the client is receptive of the education. The client verbalizes not being ready to learn, so education should be discontinued and continued at another time. Asking for permission to teach a family member does not encourage the client to learn self-care and acquire independence. The client does not need medication for anxiety at this time. This is a normal reaction. It would not be productive to continue the education because the client is not ready to learn.

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? a. Review with the client the risks and benefits of surgery. b. Ask the client to discuss the decision with family members. c. Discuss with the client the reasons for declining surgery. d. Notify the physician of the client's refusal.

c. 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 nurse is caring for a client with congestive heart failure. The nurse manager informs the nurse that the client was enrolled in a clinical trial to assess whether a 10-minute walk, 3 times per day, leads to expedited discharge. Which type of evaluation best describes what the researchers are examining? a. Process b. Structure c. Outcome d. Cost-effectiveness

c. Outcome Outcome evaluation focuses on measurable changes in the health status of the client or the end results of nursing care, such as an expedited discharge of the client based on the client recovering more quickly due to an intervention. The focus of a process evaluation is the nature and sequence of activities carried out by nurses implementing the nursing process. A structure evaluation or audit focuses on the environment in which care is provided. Cost-effectiveness is not a type of evaluation identified by the American Nurses Association.

As part of a client's plan of care, a nurse teaches a client's spouse how to perform a dressing change to the client's abdominal wound. Which method would be most effective to determine whether the spouse has mastered the skill? a. Spouse lists the signs of healing. b. Spouse identifies the steps for the dressing change. c. Spouse performs the steps of the dressing change correctly. d. Spouse shows the nurse what supplies are needed.

c. Spouse performs the steps of the dressing change correctly. The only way to be sure that clients or family caregivers have mastered a skill is watching them perform it. Once the nurse observes them doing a procedure correctly, the nurse can be confident that learning—as well as teaching—has occurred. The other answer options only demonstrate that the spouse has learned the cognitive aspects to related to the skill; the spouse can only demonstrate full, effective knowledge of the skill by performing it.

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. a. The client is male. b. The client is married. c. The client is blind. d. The client is an architect. e. The client denies the need for education.

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

c. The client with continuous pulse oximetry who requires pharyngeal suctioning. The nurse needs to perform the pharyngeal suctioning of the client with continuous pulse oximetry. This client requires the nurse to evaluate the client's response in pulse oximetry to the suctioning. The nurse can delegate the other clients to the unlicensed assistive personnel.