CH 17 - Implementing

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. A. The client is able to answer the nurse's questions. B. The client tells the nurse that the client's spouse will handle the care. C. The client discusses the specifics of what was taught during the session. D. The client verbalizes understanding of the instructions. E. The client asks the nurse to repeat the instructions.

A, C, D

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 client's refusal with hospital risk managers. C. Discuss the risks and benefits of a blood transfusion with the client. D. Discuss the client's options with other church members.

A. Discuss possible alternatives to a blood transfusion with the physician.

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? A. Make changes in the plan of care based upon assessment data. B. Discuss the desired outcomes with the client and the importance of the outcomes. C. Provide information to the client on the benefits of complying with the plan of care. D. Ask the client's family to assist the client in following the plan of care.

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

The primary purpose of nursing implementation is to: A. help the client achieve optimal levels of health. B. improve the client's postoperative status. C. implement the critical pathway for the client. D. identify a need for collaborative consults.

A. help the client achieve optimal levels of health.

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? A. "It is a habit that nurses develop in school." B. "We ask your name to ensure that we are treating the right client." C. "We ask your name to show that we respect your rights." D. "It is a hospital policy to reduce the potential for errors."

B. "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? 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.

B. Collaborate with other disciplines to revise the discharge plans.

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? A. Repositioning to prevent pressure injuries B. Ensuring that the endotracheal tube is secure C. Changing the dressing to prevent infection D. Providing medication for agitation

B. Ensuring that the endotracheal tube is secure

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

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

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? A. Document the client's ambulation. B. Discuss the client's feelings about the illness. C. Assess the client's response to the ambulation. D. Inform the client when ambulation is scheduled next.

C. Assess the client's response to the ambulation.

Which is the nurse's priority question to consider prior to delegating a task to an unlicensed assistive personnel (UAP)? A. What is the client's condition? B. How can I supervise the completion of this task? C. Does this task fall within the scope of a UAP? D. How can I explain the task to the UAP?

C. Does this task fall within the scope of a UAP?

The nurse is preparing a client with a bowel obstruction for emergency surgery. Which intervention has the highest priority for this client? A. Instruct the client and family in wound care. B. Discuss discharge plans with the client. C. Inform the client what to expect after the surgery. D. Teach the client about dietary restrictions during recovery.

C. Inform the client what to expect after the surgery.

Which action should the nurse take to ensure that an unlicensed assistive personnel (UAP) understands the instructions to perform a delegated task? A. Request that the UAP place the steps of the task in the framework of the nursing process. B. Ask another UAP to observe and assist the UAP in performing the task. C. Instruct the UAP to repeat the instructions to be sure the nurse has communicated clearly. D. Inform the UAP of the importance of following each step listed in the procedure manual.

C. Instruct the UAP to repeat the instructions to be sure the nurse has communicated clearly.

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? A. Emphasize to the client the importance of following the treatment plan. B. Ambulate the client and medicate later. C. Medicate the client and wait to ambulate later. D. Explain to the client the benefits of ambulation.

C. Medicate the client and wait to ambulate later.

When the nurse enters the room to assess a client's vital signs, the client insists that the nurse perform handwashing. What is the nurse's most appropriate action? A. Tell the client that gloves are required for this procedure. B. Reassure the client that the nurse knows when to perform hand hygiene. C. Praise the client for taking an active role in the client's care. D. Inform the client that it is not necessary to wash hands before vital signs.

C. Praise the client for taking an active role in the client's care.

Which task would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? A. Retrieve a unit of blood from the blood bank. B. Assess an IV site for possible infiltration C. Provide the client with assistance in transferring to the bedside commode. D. Reassess the client's sacrum for redness when doing a bed bath.

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

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? A. Maintenance B. Collaborative C. Surveillance D. Supportive

C. Surveillance

The registered nurse is working with an unlicensed assistive personnel. Which client should the nurse not delegate to the unlicensed assistive personnel? A. The client who needs vital signs taken following infusion of packed red blood cells. B. The client who requires assistance dressing in preparation for discharge. C. The client with continuous pulse oximetry who requires pharyngeal suctioning. D. The client who is pleasantly confused and requires assistance to the bathroom.

C. The client with continuous pulse oximetry who requires pharyngeal suctioning.

The nurse is attending a conference on evidence-based practice. Which statement by the nurse indicates further education is needed? A. "Nursing interventions should be supported by a sound scientific rationale." B. "The Agency for Healthcare Research and Quality is a resource for evidence-based practice." C. "I can learn about evidence-based practice by reading professional nursing journals." D. "I must conduct research to validate the usefulness of my nursing interventions."

D. "I must conduct research to validate the usefulness of my nursing 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? A. Instruct the client that pain medication is available at regular intervals. B. Perform additional nonpharmacological pain interventions. C. Notify the physician that the client has required pain medications. D. Reassess the client to determine the effectiveness of the interventions.

D. Reassess the client to determine the effectiveness of the interventions.

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? A. Tell the UAP not to ambulate the client at this time. B. Tell the UAP that a different UAP should ambulate the client. C. Tell the UAP to ask the client whether the client is comfortable with the UAP assisting ambulation. D. Tell the UAP that the RN will assist the UAP with the client's ambulation.

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