chapter 17-prep u
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?
Ask a skilled nurse to assist with the procedure.
The nurse is caring for several clients. Which intervention can the nurse direct the unlicensed assistive personnel (UAP) to perform?
Bathe a client with stable angina who has a continuous IV infusing.
Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?
Bed bath for the newly admitted client who has multiple skin lesions
A nurse is catheterizing a client. Which scenario demonstrates steps the nurse would take to ensure client respect and privacy?
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.
After instituting interventions to increase oxygenation, the client shows no signs of improvement. What is the nurse's priority action?
Communicate with the health care provider for additional orders.
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 health care provider.
Which is the nurse's priority question to consider prior to delegating a task to an unlicensed assistive personnel (UAP)?
Does this task fall within the scope of a UAP?
Which action is a nursing intervention that facilitates lifespan care?
Educate family members about normal growth and development patterns.
The nurse is preparing a client to be discharged from the surgical unit following abdominal surgery. Which intervention will the nurse use to ensure the client's adherence to proper wound care techniques?
Include family members or other caregivers in the education.
Which action should the nurse take to ensure that an unlicensed assistive personnel (UAP) understands the instructions to perform a delegated task?
Instruct the UAP to repeat the instructions to be sure the nurse has communicated clearly.
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?
Make changes in the plan of care based upon assessment data.
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
The client reports right knee pain of 6/10 on the pain scale and requests medication. The nurse assesses and flushes the intravenous site. Which type of intervention skill is the nurse using?
Technical skill
A new unlicensed assistive personnel (UAP) is preparing to ambulate an obese client. The registered nurse (RN) is concerned about the UAP's ability to safely ambulate the client. Which would be the nurse's most appropriate action?
Tell the UAP that the RN will assist the UAP with the client's ambulation.
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 3 years.
The registered nurse is working with an unlicensed assistive personnel. Which client should the nurse not delegate to the unlicensed assistive personnel?
The client with continuous pulse oximetry who requires pharyngeal suctioning.
The Joint Commission (TJC) encourages clients to become active, involved, and informed participants on the health care team. What nursing action follows TJC recommendations for improving client safety by encouraging them to speak up?
The nurse encourages the client to participate in all treatment decisions as the center of the health care team.
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 health care provider has examined the client. For the nurse to be operating within the nurse's scope of practice, what conditions must be present?
The nurse is operating under standing orders for clients with suspected MIs.
A student nurse is on a clinical rotation at a busy hospital unit. The RN in charge tells the student to change a surgical dressing on a patient while she takes care of other patients. The student has not changed dressings before and does not feel confident performing the procedure. What would be the student's best response?
a. Tell the RN that he or she lacks the technical competencies to change the dressing independently. Student nurses should notify their nursing instructor or nurse mentor if they believe they lack any competencies needed to safely implement the care plan. It is within the realm of a student nurse to change a dressing if he or she is technically prepared to do so.
An RN working on a busy hospital unit delegates patient care to UAPs. Which patient care could the nurse most likely delegate to a UAP safely? Select all that apply.
b-Making patient beds c-Giving patients bed baths e-Ambulating patients f-Assisting patients with meals Performing the initial patient assessment and administering medications are the responsibility of the RN. In most cases, patient hygiene, bed-making, ambulating patients, and helping to feed patients can be delegated to a UAP.
A nurse develops a detailed care plan for a 16-year-old patient who is a new single mother of a premature infant. The plan includes collaborative care measures and home health care visits. When presented with the plan, the patient states, "We will be fine on our own. I don't need any more care." What would be the nurse's best response?
c. "Let's take a look at the plan again and see if we can adjust it to fit your needs." When a patient does not follow the care plan despite your best efforts, it is time to reassess strategy. The first objective is to identify why the patient is not following the therapy. If the nurse determines, however, that the care plan is adequate, the nurse must identify and remedy the factors contributing to the patient's noncompliance.
A new RN is being oriented to a nursing unit that is currently understaffed and is told that the UAPs have been trained to obtain the initial nursing assessment. What is the best response of the new RN?
c. Tell the charge nurse that he or she chooses not to delegate the admission assessment until further clarification is received from administration. The nurse should not delegate this nursing admission assessment because only nurses can perform this intervention. The nurse should seek clarification for this policy from the nursing administration.
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.
A nurse follows set guidelines for administering pain medication to clients in a critical care unit. This nurse's authority to initiate actions that normally require the order or supervision of a health care provider is termed:
standing orders.
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?
unlicensed assistive personnel who is in nursing school
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?
"It seems like you are having difficulty with your care regimen."
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?
"We ask your name to ensure that we are treating the right client."
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.
-Assisting the client with personal hygiene needs and ambulation -Transporting the infant to the mother's room according to hospital policy
Which are appropriate guidelines for the nurse to follow when delegating tasks to an unlicensed assistive personnel (UAP)? Select all that apply.
-Delegate tasks that are within the UAP's scope of practice. -Delegate tasks that involve minimal risk. -Provide appropriate supervision when delegating tasks. -Provide feedback to the UAP after the task is completed.
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 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 long-term safety?
Assist the client to identify strategies to promote safety in the home.
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.
A nurse is preparing to educate a client about self-care after cataract surgery. Which should the nurse do first?
Determine the client's willingness to follow the regimen.
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?
Discontinue the education and attempt at another time.
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 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?
Go to the client and assess the client's pain.
A nurse is caring for a postoperative client who reports a pain level of 6 on a scale from 1 to 10. After administering the prescribed pain medication, which intervention should the nurse include in the nursing care plan to monitor and evaluate pain?
Implement the ABC guide of pain management.
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?
Outcome
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.
Before implementing any planned intervention, which action should the nurse take first?
Reassess the client to determine whether the action is needed.
A client is admitted to the mental health center after attempting suicide. Which client concern is the priority for the nurse to manage?
Risk of self-harm
The nurse is caring for a postoperative client who is receiving morphine sulfate for pain management. The nurse obtains the following vital signs: heart rate, 74 beats/min; respiratory rate, 8 breaths/min; blood pressure, 114/68 mm Hg. After reviewing the nursing care plan and health care provider orders, the nurse administers naloxone. Which would allow the nurse to initiate this action?
Standing orders
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?
Surveillance
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?
Surveillance
A nurse who is experienced caring only for well babies is assigned to the neonatal intensive care unit (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 school nurse notices that a student is losing weight and decides to perform a focused nutritional assessment to rule out an eating disorder. What is the nurse's best action?
a. Perform the focused assessment as this is an independent nurse-initiated intervention. Performing a focused assessment is an independent nurse-initiated intervention; thus the nurse does not need an order from the physician or the nutritionist.
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."
The nurse is working with a client who is having a difficult time accepting a new diagnosis of type 2 diabetes. The nurse pulls up a chair and holds the client's hand while listening to the client's concerns. What additional type of nursing supportive intervention could the nurse provide?
Arranging for clergy to visit with the client
Which is an independent (nurse-initiated) action?
Helping to allay a client's fears about surgery
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.
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?
Ask the surgeon to wait until the client has had a chance to talk to the spouse.
In the implementation step of the nursing process, which activity is the nurse's first priority?
Reassess client's needs.
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?
Identify what barriers the client feels are preventing adherence with the plan.
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 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?
unlicensed licensed personnel
A nurse is using the implementation step of the nursing process to provide care for patients in a busy hospital setting. Which nursing actions best represent this step? Select all that apply.
a-The nurse carefully removes the bandages from a burn victim's arm. d-The nurse turns a patient in bed every 2 hours to prevent pressure injuries. f-The nurse checks for community resources for a patient with dementia. During the implementing step of the nursing process, nursing actions planned in the previous step are carried out. The purpose of implementation is to assist the patient in achieving valued health outcomes: promote health, prevent disease and illness, restore health, and facilitate coping with altered functioning. Assessing a patient for nutritional status or insurance coverage occurs in the assessment step, and formulating nursing diagnoses occurs in the diagnosing step.
A nurse is using the implementation step of the nursing process to provide care for patients in a busy hospital setting. Which nursing actions best represent this step? Select all that apply.
b. Nursing interventions, each with a label, a definition, and a set of activities that a nurse performs to carry it out, with a short list of background readings The NIC Taxonomy lists nursing interventions, each with a label, a definition, a set of activities that a nurse performs to carry it out, and a short list of background readings. It does not contain case studies, diagnoses, or charges.
A nurse is about to perform pin site care for a patient who has a halo traction device installed. What is the FIRST nursing action that should be taken prior to performing this care?
b. Reassess the patient. Before implementing any nursing action, the nurse should reassess the patient to determine whether the action is still needed. Then the nurse may collect the equipment, explain the procedure, and, if necessary, administer pain medications.
A nurse performs nurse-initiated nursing actions when caring for patients in a skilled nursing facility. Which are examples of these types of interventions? Select all that apply.
c-A nurse checks the skin of bedridden patients for skin breakdown. d-A nurse orders a kosher meal for an orthodox Jewish patient. f-A nurse prepares a patient for minor surgery according to facility protocol. Nurse-initiated interventions, or independent nursing actions, involve carrying out nurse-prescribed interventions resulting from their assessment of patient needs written on the nursing care plan, as well as any other actions that nurses initiate without the direction or supervision of another health care professional. Protocols and standard orders empower the nurse to initiate actions that ordinarily require the order or supervision of a health care provider. Consulting with a psychiatrist is a collaborative intervention.
A student nurse is organizing clinical responsibilities for a patient who is diabetic and is being treated for foot ulcers. The patient tells the student, "I need to have my hair washed before I can do anything else today; I'm ashamed of the way I look." The patient's needs include diagnostic testing, dressing changes, meal planning and counseling, and assistance with hygiene. How would the nurse best prioritize this patient's care?
d. Arrange to wash the patient's hair first, perform hygiene, and schedule diagnostic testing and counseling. As long as time constraints permit, the most important priorities when scheduling nursing care are priorities identified by the patient as being most important. In this case, washing the patient's hair and assisting with hygiene puts the patient first and sets the tone for an effective nurse-patient partnership.
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
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.
Which nursing action can be categorized as a surveillance or monitoring intervention?
Auscultating of bilateral lung sounds
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?
Discuss with the client the reasons for declining surgery.
A client cannot afford the treatment prescribed. Who would be the most appropriate professional for the nurse to involve with the client's care?
Nurse case manager
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?
Risk factors for and prevention of diabetes mellitus
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?
To give the client the opportunity to actively participate in care
