Foundations Chapter 14 PrepU

Discuss possible alternatives to a blood transfusion with the physician.

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?

Collaborate with other disciplines to plan end-of-life care for the client.

A client in the last stages of pancreatic cancer tells the nurse, "I am tired of fighting. I am ready to die." What is the nurse's best action?

an asthma client who reports shortness of breath with a respiratory rate of 26 bpm

A nursing student received a report on his assigned clients for the clinical day. Which client should the student nurse plan to assess first?

Listen to the new nurse's suggestion and evaluate its usefulness.

The RN is orienting a new nurse who suggests a different way to perform a procedure. What is the RN's most appropriate reaction?

Bathe a client with stable angina who has a continuous IV infusing.

The nursing is caring for several clients. Which client can the nurse delegate to the unlicensed assistive personnel?

auscultating of bilateral lung sounds

Which nursing action can be categorized as a surveillance or monitoring intervention?

Communicate with the physician for additional orders.

After instituting interventions to increase oxygenation, the client shows no signs of improvement. What is the nurse's priority action?

Psychosocial background

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?

Delegate tasks that follow the individual's scope of practice. Delegate tasks that involve minimal risk. Provide appropriate supervision when delegating tasks. Provide feedback after task is completed.

Delegating responsibilities is one of the tools the nurse uses during client care. Which statement is appropriate when delegating?

Surveillance 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?

Collecting additional client data Modifying the client plan of care

Nurses implement care for clients in various health care settings. Which activities would typically be carried out during the implementation step of the nursing process? Select all that apply.

Helping to allay a patient's fears about surgery

Nurses perform many independent nursing actions when caring for patients. Which action is considered an independent (nurse-initiated) action?

teaching decision making allocating nursing resources developing information systems communicating nursing to non-nurses

Nurses utilize the McCloskey, Dochterman, and Bulechek Nursing Interventions Classification (NIC) report of research when choosing nursing interventions for clients. What are advantages of having standard Nursing Interventions Classifications (NIC)? Select all that apply.

Finances of the client

Priority setting is based on the information obtained during reassessment. Priority setting is used to rank nursing diagnoses. Each of the following contributes to priority setting except which of the following?

Make changes in the plan of care based upon assessment data.

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?

Determine the client's willingness to follow the regimen.

The nurse caring for a client who is recovering after a motor vehicle accident is planning for the client to begin increasing responsibility for self-care. What would be the nurse's most appropriate strategy?

Surveillance

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?

Assess the client's response to the ambulation.

The nurse has assisted the client to ambulate for the first time. After returning the client to bed, what is the nurse's priority intervention?

Delay the instruction until the visitors leave.

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?

help the client achieve optimal levels of health.

The primary purpose of nursing implementation is to:

The client verbalizes understanding of the instructions. The client is able to answer the nurse's questions. The client discusses the specifics of what was taught during the session.

What assessment data would indicate to the nurse at the conclusion of an education session that the client education was effective? Mark all that apply.

Ask a skilled nurse to assist with the procedure.

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?

It enables the nurse to revise the care plan appropriately.

As the nurse bathes a patient, she notes his skin color and integrity, his ability to respond to simple directions, and his muscle tone. Which statement best explains why such continuing data collection is so important?

Report the findings to the physician for further plans.

A client with hypertension being seen for follow-up care has a blood pressure of 160/100. 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?

The nurse should inform the charge nurse that she does not have the experience to properly care for this client.

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?

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

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?

The client with continuous pulse oximetry who requires pharyngeal suctioning.

The registered nurse is working with an unlicensed assistive personnel. Which client should the nurse not delegate to the unlicensed assistive personnel?

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

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?

Assess for bladder distention.

The nurse is caring for a client admitted to the hospital for renal calculi. What is the action to take first?

Inform the client what to expect after the surgery.

The nurse is preparing a client with a bowel obstruction for emergency surgery. Of the following interventions, which has the highest priority?

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

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?

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

The nursing student 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?

Assess the client to determine the cause of the pain.

One hour after receiving pain medication, a postoperative client reports intense pain. What is the nurse's appropriate first action?

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

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.

"I will not work tomorrow because I would be a danger to my clients."

The nurse is currently completing the last of three consecutive night shifts. The unit will be short-staffed on day shift and the charge nurse wants the nurse to work this as an overtime shift. What is the nurse's most appropriate response?

Risk factors and prevention of diabetes mellitus

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?

The client is blind. The client denies the need for education.

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.

Discuss with the client the reasons for declining surgery.

The nurse is preparing a client for surgery when the client tells the nurse that he no longer wants to have the surgery. How should the nurse most appropriately respond?

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

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?

Provide client assistance to the bedside commode.

The nurse is to delegate certain tasks to unlicensed assistive personnel (UAP). Which of the following tasks can be appropriately assigned to a UAP?

Call the physician to clarify the order.

The physician has ordered 100 mg of morphine sulfate IM to a client. The nurse knows that the usual dose is 10 mg of morphine sulfate. What is the nurse's most appropriate action?

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

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?

Reassess the client to determine the effectiveness of the interventions.

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?

Collaborate with other disciplines to revise the discharge plans.

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?

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

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?

Medicate the client and wait to ambulate later.

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?

We ask your name to ensure that we are treating the right client."

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?

The task is delegated to a person with sufficient knowledge and skill for completing the task. Instructions have been clearly communicated by the nurse to the unlicensed assistive personnel. The unlicensed assistive personnel can verbalize what information is to be reported to the nurse.

Which are essential components for delegating nursing care? Select all that apply.

The task is delegated to a person with sufficient knowledge and skill for completing the task. Instructions have been clearly communicated by the nurse to the unlicensed assistive personnel. The unlicensed assistive personnel can verbalize what information is to be reported to th

Which are essential components for delegating nursing care? Select all that apply.

Educate family members about normal growth and development patterns.

Which of the following is a nursing intervention that facilitates life span care?

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

Which of the following nursing interventions is most likely to be allowed within the parameters of a protocol or standing order?

closing the door to the room

A nurse is catheterizing a client. Which action illustrates respect for the client's privacy?

Equipment and personnel

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. Which has the nurse failed to organize?

Go to the client and assess the client's pain.

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?

Psychosocial Supportive

The client is about to have blood drawn before seeing the health care provider. The spouse while smiling and holding the client's hand, states "Here comes the blood sucker. It is going to hurt bad." This statement is an example of which type of intervention? Select all that apply.

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

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?

Reassess the appropriateness of the method of instruction.

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?

Nursing assistant

The nurse is assigned a client who had an uneventful colon resection two days ago and requires a dressing change. To which nursing team member should the nurse avoid delegating the dressing change?

creation of a standardized language assistance in determining the cost of services that nurses provide demonstration of the impact of nurses

The nurse is assigning interventions to achieve the goals set for a client using the nursing intervention classification (NIC). What is the benefit of using this system for the development of interventions? Select all that apply.

"I must conduct research to validate the usefulness of my nursing interventions."

The nurse is attending a conference on evidence-based practice. Which statement by the nurse indicates further education is needed?

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

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?

Standing orders

The nurse is caring for a postoperative client who is receiving morphine sulfate for pain management. The nurse obtains the following vital signs. HR 74 RR 8 BP 114/68. After reviewing the nursing care plan and physician orders, the nurse administers naloxone (Narcan). What would allow the nurse to initiate this action?

Collaborate with the nutritionist to modify the nutritional plan.

The nurse is caring for a vegetarian who is suffering from iron deficiency anemia. The nutritional plan for a client with anemia calls for the client to increase consumption of animal protein. How will the nurse plan to meet this client's nutritional needs?

Nursing assistant who is a nursing student

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?

Reschedule the client's bath to the evening shift.

The nurse is preparing to give the client a bath early in the morning. The client states, "I prefer to take my bath at night. It helps me sleep." What is the nurse's most appropriate action?