Fundamentals Ch. 17

Which statement by a nurse case manager regarding this nurse's role in client care is most accurate?

"I provide indirect care to my clients by coordinating their treatment with other disciplines."

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."

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?

"You should always speak up if you have any questions about your care."

Which examples are essential components for delegating nursing care to an unlicensed assistive personnel (UAP)? Select all that apply.

- The nurse has clearly communicated instructions to the UAP. - The UAP has sufficient knowledge and skill for completing the task. - The UAP can verbalize what information to report to the nurse.

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 mostappropriate action?

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

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.

The nursing 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

Which parties are essential for the nurse to include in the implementation of a client's plan of care?

Client, family, and physician

The nurse is caring for a client who is recovering from a cerebrovascular accident. When reviewing the client's orders, the nurse notes that one of the physicians wrote orders to ambulate the client, whereas another physician ordered strict bed rest for the client. How would the nurse mostappropriately remedy this conflict?

Communicate with the physicians to coordinate their orders.

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.

A nurse is catheterizing a client. Which scenario demonstrates steps the nurse would take to ensure client respect and privacy?

Explain the procedure to the client, close the door to the room, and cover all areas of the client, only exposing the area for catheterization.

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 understands proper wound care techniques?

Include family members or other caregivers in the education.

Which statement best explains why continuing data collection is important?

It enables the nurse to revise the care plan appropriately.

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?

Medicate the client and wait to ambulate later.

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

Which task would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)?

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

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

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 physician is termed:

Standing Orders

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 client has a diagnosis of Risk for Injury related to falls. How would the nurse know if the intervention was successful?

The client is free of falls.

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.

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?

Nursing assistant

A nurse is developing a plan of care for a client and determines appropriate outcomes and interventions for this client. Which variable would be most appropriate for the nurse to address to ensure that the care plan meets the client's needs? Select all that apply.

- Client's ability to participate - Client's developmental stage - Client's cultural background - Client's socioeconomic status

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."

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?

Collaborate with other disciplines to revise the discharge plans.

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.

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

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 restaraunt 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

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 primary purpose of nursing implementation is to:

help the client achieve optimal levels of health.

Which nursing action would be most effective in helping a client learn self-care behaviors?

Model self-care behaviors for the client.

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."

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

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

Auscultating of bilateral lung sounds

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?

Collaborate with the nutritionist to modify the nutritional plan.

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?

Coordinating

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.

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?

Perform vital signs and blood glucose level.

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?

Recognize the nurse's own limitations and ask for another nurse to be assigned.

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 physician orders, the nurse administers naloxone. Which would allow the nurse to initiate this action?

Standing Orders

Which is an independent (nurse-initiated) action?

Helping to allay a client's fears about surgery

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

Assess the client to determine the cause of the pain.

What are the advantages of using standard Nursing Interventions Classifications (NIC)? Select all that apply.

- Communicating nursing to non-nurses - Developing information systems - Teaching decision making - Allocating nursing resources

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 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

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?

The nurse is operating under standing orders for clients with suspected MIs.

Before implementing a nursing intervention, which question(s) will the nurse ask oneself? Select all that apply.

- "Do any health care provider prescriptions need to be clarified?" - "Can I do the intervention alone or do I need help?" - "Is the client prepared for what needs to be done?" - "Do I have all the necessary supplies and equipment needed?" - "Do I have the skills to perform the intervention?"

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.

What are the goals of the research that is behind the Nursing Outcomes Classification (NOC) system? Select all that apply.

- To define and test measurement procedures for the outcomes and indicators - To identify, label, and validate nursing-sensitive client outcomes and indicators - To evaluate the validity and usefulness of the classification in clinical field testing

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.

- Transporting the infant to the mother's room according to hospital policy - Assisting the client with personal hygiene needs and ambulation

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?

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

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?

Report the findings to the physician for further plans.

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.

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 physician.

The nurse in a burn intensive care unit (BICU) is caring for a 3-year-old child who was burned with scalding hot water. The client has burns covering 75% of the body. The client's condition is critical but stable. At 1000, the nurse reassesses the client and finds that the client is agitated and pulling at the endotracheal tube. Which is the nurse's priority intervention for this client at this time?

Ensuring that the endotracheal tube is secure

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

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 mostappropriate course of action?

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