Chapter: Chapter 14: Implementing

The nurse is to delegate certain tasks to unlicensed assistive personnel (UAP). Which of the following tasks can be appropriately assigned to a UAP? a) Reassess the client's sacrum for redness when doing bed bath. b) Secure the client's jewelry before surgery. c) Provide client assistance to the bedside commode. d) Request the UAP to get the unit of blood from the blood bank.

Provide client assistance to the bedside commode. Assisting with toileting is one of the tasks permitted by the state board of nursing for UAP. This task is commonly performed by UAP in health facilities.

A client who has been in a vegetative state for years is scheduled for an elective surgery. The nurse is questioning whether the procedure is necessary. What is the nurse's most appropriate first action? a) The nurse should address the concern with the hospital attorney. b) The nurse should address the concern with the hospital ethics committee. c) The nurse should address the concern with the client's family. d) The nurse should address the concern with the surgeon.

The nurse should address the concern with the surgeon. The nurse should first address the concern with the surgeon who has scheduled the procedure. If the nurse still has concerns after the discussion with the surgeon, the other choices are possible courses of action

A client recovering after an appendectomy is reporting pain. The nurse administers the ordered pain medication and assists the client to splint the incision. What is the nurse's next step in implementing the plan of care? A client recovering after an appendectomy is reporting pain. The nurse administers the ordered pain medication and assists the client to splint the incision. What is the nurse's next step in implementing the plan of care? a) Notify the physician that the client has required pain medications. b) Reassess the client to determine the effectiveness of the interventions. c) Perform additional non-pharmacologic pain interventions. d) Instruct the client that pain medication is available at regular intervals.

Reassess the client to determine the effectiveness of the interventions.

An 84-year-old male has been admitted to the hospital several times in the past few months for exacerbations of chronic obstructive pulmonary disease (COPD) and elevated blood glucose. Which statement by the client could help identify the most likely reason for the changes in his health status? a) "I asked my neighbors to help me with my yard work." b) "My wife's been gone for about 7 months now." c) "I sort my medication into an organizer every week." d) "My daughter has been staying with me the past few weeks."

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

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) Instruct the client to make alternate living arrangements. b) Collaborate with other disciplines to revise the discharge plans. c) Communicate with the physician about additional orders. d) Inform the family that it is not possible to change the discharge plans.

Collaborate with other disciplines to revise the discharge plans. Correct

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

Outcome evaluation

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

help the client achieve optimal levels of health.

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) Ask a skilled nurse to assist with the procedure. c) Read the policy and procedure manual. d) Determine the necessity of the bag change.

Ask a skilled nurse to assist with the procedure.

The nurse is caring for a client admitted to the hospital for renal calculi. What is the best action to take first? a) Diet as tolerated. b) Force fluids by mouth. c) Strain urine after each void. d) Assess for bladder distention.

Assess for bladder distention.

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

Assess the client's blood pressure to determine if the medication is indicated.

The mother of a pediatric client being discharged confides to the nurse that her husband is abusive and she is afraid to return home. What is the nurse's most appropriate action? a) Give the mother telephone numbers of women's shelters. b) Coordinate with the case manager to make a safe discharge plan. c) Advise the mother that she should report her concerns to the police. d) Arrange for a counseling session for the parents of the client.

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

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 possible alternatives to a blood transfusion with the physician. b) Discuss the risks and benefits of a blood transfusion with the client. c) Discuss the client's refusal with hospital risk managers. d) Discuss the client's options with other church members.

Discuss possible alternatives to a blood transfusion with the physician.

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

Inform the client what to expect after the surgery.

In the implementation step of the nursing process, a nurse is to utilize certain activities to be effective in the care of a client. Which activity is of highest priority? a) Differentiate between subjective and objective data. b) Reassess client's needs. c) Document nursing care. d) Prioritize evaluation of care.

Reassess client's needs.

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) Instruct the client's family to assist the client to ambulate to the bathroom. 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) Revise the care plan to allow the client to ambulate to the bathroom independently.

Revise the care plan to allow the client to ambulate to the bathroom independently.

The nurse is discussing diabetes mellitus with the family members of a client recently diagnosed. In order to promote the health of the family members, what would be the most important information for the nurse to include? a) Risk factors and prevention of diabetes mellitus b) Medications used to treat diabetes mellitus c) The cellular metabolism of glucose d) The severity of the client's disease

Risk factors and prevention of diabetes mellitus

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

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

Which nursing action can be categorized as a surveillance or monitoring intervention? a) auscultating of bilateral lung sounds b) providing hygiene c) use of therapeutic communication skills d) administering paracetamol tablet

auscultating of bilateral lung sounds

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

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

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

Reassess the appropriateness of the method of instruction.

The nurse is working with Ms. V. today. Ms. V. is having a difficult time accepting her new diagnosis of type 2 diabetes. Thenurse pulls up a chair next to Ms. V.'s bed and holds her hand while listening to her story. What type of nursing intervention is the nurse engaging in? a) Supportive intervention b) Supervisory intervention c) Psychosocial intervention d) Coordinating intervention

Supportive intervention

Nurse Mayweather is auscultating lung sounds. She notes crackles in the LLL which were not present at the start of the shift. Nurse Mayweather is engaged in which type of nursing intervention? a) Educational intervention b) Maintenance intervention c) Surveillance intervention d) Psychomotor intervention

Surveillance intervention Surveillance interventions include detecting changes from baseline data and recognizing abnormal response. Nurses rely on the senses to detect changes: observing the appearance and characteristics of clients; hearing by auscultation, pitch, and tone. Nurses use these surveillance activities to determine the current status of clients and changes from previous states.

The student nurse is preparing to ambulate an obese client. The RN is concerned about the student's ability to safely ambulate the client. What would be the nurse's most appropriate action? a) Tell the student that the nursing assistant should ambulate the client. b) Tell the student to ask the client if the client is comfortable with the student assisting ambulation. c) Tell the student not to ambulate the client at this time. d) Tell the student that the RN will assist the student with the client's ambulation.

Tell the student that the RN will assist the student with the client's ambulation.

A nurse who is experienced caring only for well babies is assigned to the newborn intensive care nursery (NICU) because of a shortage of nurses in the NICU. The nurse is assigned to an infant on a ventilator who will require blood transfusions during the shift. What is the nurse's most appropriate course of action? a) The nurse should inform the charge nurse that she does not have the experience to properly care for this client. b) The nurse should recognize the necessity of the assignment and provide care to the best of her ability. c) The nurse should ask another nurse who was previously assigned to the client for instruction. d) The nurse should request that the blood transfusions be delayed until the next shift.

The nurse should inform the charge nurse that she does not have the experience to properly care for this client. The nurse should recognize that she lacks the competence to safely care for a client with these complex needs and inform the charge nurse of the fact. This assignment would be an inappropriate delegation on the part of the charge nurse and could cause injury to the client. The other options do not take the safety of the client into consideration.