PrepU Chapter 17: Implementing

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. Explanation: 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.

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. Explanation: If the nurse's interventions have been ineffective, the health care provider must be notified of the client's deteriorating status. The health care provider 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.

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? Explanation: All of these questions are important, but the priority is whether the task falls within the scope of a UAP. If the answer is no, the rest of the questions are not necessary.

Which is the priority question for the nurse to consider before implementing a new intervention?

Does this treatment make sense for this client? Explanation: All of these questions are important, but the priority is whether the treatment makes sense for the client. If not, answering the other questions is unnecessary.

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. Explanation: 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?

Reassess the client to determine whether the action is needed. Explanation: 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 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 Explanation: 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?

Surveillance Explanation: 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 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. Explanation: 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.

The nursing team, consisting of a nurse and experienced unlicensed assistive personnel (UAP), have worked well together for the past year. The nurse instructs the UAP to feed a stable stroke client, assist with dressing a client in preparation for discharge, and take vital signs of a third client in addition to notifying the nurse if the blood pressure becomes low. Which error has the nurse made?

The nurse failed to communicate clear instructions regarding what constitutes a low blood pressure. Explanation: The nurse failed to communicate clear instructions to the UAP. The delegated tasks are not too numerous and are within the scope of a UAP's role and responsibilities. The nurse has had ample opportunity to validate the UAP's knowledge and skill to perform the tasks, as they have worked together for the past year.

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

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?

Spouse performs the steps of the dressing change correctly. Explanation: 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 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. Explanation: 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 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. Explanation: TJC encourages clients to become active, involved, and informed participants on the health care team. By becoming involved and "speaking up" research shows that clients who take part in decisions about their health care are more likely to have better outcomes. The nurse should never want to prevent client questions. While clients are encouraged to be independent, trusted family members and friends can be an asset to the client's care. The nurse should investigate the possibility of an error if the client questions the nurse about a medication.

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 Explanation: 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 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 Explanation: 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.

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. Explanation: The nurse should recognize that the nurse 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.

An 87-year-old client has been admitted to the hospital several times in the past few months for exacerbations of chronic obstructive pulmonary disease and elevated blood glucose levels. Which statement by the client could help identify the most likely reason for the changes in the client's health status?

"My wife's been gone for about 7 months now." Explanation: The client's loss may be affecting how well the client is able to provide self-care. The client may be depressed and questioning the benefits of the health care regimen, or the client may have depended on the wife to help with health care and no longer has the ability to take care of himself. Assessment of the client allows the nurse to alter the plan of care to meet the client's needs. The statements concerning having a family member staying with the client, having help with the yard work, and sorting medications into an organizer all indicate factors that would improve the client's ability to provide self-care, not decrease it.

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

-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. Explanation: After an intervention is implemented, the nurse must assess the effectiveness of the intervention. The client stating an understanding of the instructions gives the nurse an indication that learning has taken place. Asking the client questions and receiving the correct answers is an excellent way to judge the client's knowledge. The client asking for the nurse to repeat the instructions shows that the client does not have a clear understanding. The client's statement that the spouse will handle the care signals that the client is not ready to learn at this time. The client's ability to discuss the specifics of the material suggests that learning has taken place.

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. Explanation: 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?

Ask the surgeon to wait until the client has had a chance to talk to the spouse. Explanation: 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.

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. Explanation: 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.

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

Auscultating of bilateral lung sounds Explanation: 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 health care provider 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.

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

Client, family, and health care provider Explanation: To ensure the success of the care plan, the nurse must involve all necessary parties. It is essential that the client be involved in the client's own health care decisions. The client's family provides needed support, and the health care provider is essential to provide medical interventions. The hospital director is not necessary for the implementation of the plan of care. A physical therapist and a surgeon are not necessarily involved in every client's care.

A nurse is administering metformin to a client who has a new onset of diabetes mellitus type 2. Which step should the nurse consider a priority on the nursing care plan?

Monitor for lactic acidosis Explanation: In this scenario, the nurse is administering a medication. Because an action is being carried out, this is the implementation step of the nursing process. Following the administration of medication, the nurse should monitor the client for lactic acidosis as well as side effects of the medication. Restricting the client's food and fluids while the client is on metformin is only suggested when the client is preparing for a procedure requiring the client to be NPO. B12 injections may be indicated in the future as treatment has been established. Likewise, it is too early in the treatment plan to monitor for noncompliance.

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. Explanation: The nurse must take into consideration the client's developmental level and willingness to participate in care in order to successfully implement the plan of care. The client is an adolescent and socialization with a peer group is essential, so the nurse would most appropriately wait until the visitors leave. Telling the visitors to leave in 10 minutes might upset the client and hinder the education. Simply asking if the client has questions does not appropriately educate the client. Leaving written information does not ensure that the client will read or understand the information.

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. Explanation: As coordinator of the client's care, the nurse functions as an intermediary between the health care provider and the client. In order to honor the client's wishes, the nurse would most appropriately consult with the health care provider 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.

The nurse is preparing a client with a bowel obstruction for emergency surgery. Which intervention has the highest priority for this client?

Inform the client what to expect after the surgery. Explanation: 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.

Which statement best explains why continuing data collection is important?

It enables the nurse to revise the care plan appropriately. Explanation: Continuous data collection ensures that the nurse has the most current client data to evaluate, which allows for updating the care plan as needed. A complete assessment is performed on admission, but the client's condition is always changing. The purpose of continued data collection is to provide good client care; it does not relate directly to efficiency of nursing care. While continuous data collection meets standards of care, it is not the primary reason for ongoing assessments.

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. Explanation: A client 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.

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 Explanation: 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 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 Explanation: 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 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 Explanation: Technical skills are used to carry out treatments and procedures, such as assessing and flushing an intravenous site. Nurses learn the specific skills through clinical practice. Intellectual skills include the ability to explain complex disease processes and treatment regimens to a client. Interpersonal skills, such as communication, allow the nurse to establish strong relationships and build trust with the client. Mechanical skills are not among the skills nurses need.

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 best response?

Work with the evening shift to possibly reschedule. Explanation: The client's preferences are a primary consideration in scheduling interventions. The client's preference to have a bath at night requires a change in scheduling and the nurse should discuss the issue with the evening shift to determine if rescheduling is possible. Asking for permission to give the bath in the morning does not address the client's preference. The schedule of the nurses should not take priority over client desires. Informing the client about sleep medication does not address the client's preference. To just brush off the client's desires is not showing holistic nursing care.

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. Explanation: 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.