Chapter 14

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. Assist the client to reposition and splint the incision. Discuss the frequency of pain medication administration with the client. Consult with the physician for additional pain medication.

Assess the client to determine the cause of the pain.

A client has a nursing diagnosis of Possible Spiritual Distress. What is the most appropriate nursing intervention? Seek out the client's pastor for help. Offer to pray with the client. Discuss spirituality with the client. Leave the client alone for privacy.

Discuss spirituality with the client.

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? Explain the effects of a high-salt diet and smoking on blood pressure. Identify what barriers the client feels are preventing adherence with the plan. Change the nursing care plan. Collaborate with other health care professionals about the client's treatment.

Identify what barriers the client feels are preventing adherence with the plan.

A nurse is administering metformin to a client who has a new onset of diabetes mellitus type 2. Which of the following steps of nursing process is the nurse using? Planning Implementation Assessment Evaluation

Implementation

A client cannot afford the treatment prescribed. Who would be the most appropriate professional for the nurse to involve with the client's care? Physician Nurse manager Insurance company Nurse case manager

Nurse case manager

A registered nurse (RN) and a licensed practical nurse (LPN) are caring for a client who has been admitted with an acute exacerbation of chronic obstructive pulmonary disease (COPD). Which nursing actions can the RN delegate to the LPN? Select all that apply. Performing an admission assessment Auscultating breath sounds Administering an oral antibiotic Obtaining pulse oximetry Developing a nursing care plan

Obtaining pulse oximetry Auscultating breath sounds Administering an oral antibiotic

The nursing supervisor visits the emergency department and informs the department manager that tornado victims are expected to arrive within the hour. The department manager indicates the department has been slow and requests information regarding possible numbers of victims. The department manager reports supplies were just fully stocked, but two nurses are ill with influenza and were unable to report for their shift. Which resource does the department manager need to organize to respond to the disaster? Clients Equipment Environment Personnel

Personnel

Which action is a responsibility of the nurse in the nurse-nurse team relationship? Communicate nursing's perspective regarding the client and family. Intervene to promote healthy family functioning through education and advocacy. Challenge the client to develop self-care abilities that promote health. Provide creative leadership to make the nursing unit a challenging place to work.

Provide creative leadership to make the nursing unit a challenging place to work.

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? Ask the client for permission to give the bath in the morning. Tell the client that the physician has ordered sleep medication if necessary. Determine if the nurses have time to give the client's bath at night. Reschedule the client's bath to the evening shift.

Reschedule the client's bath to the evening shift.

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. What would allow the nurse to initiate this action? Protocol Standing orders Order set Algorithm

Standing orders

Mr. J. is a 56-year-old man status post admission for a myocardial infarction and coronary artery bypass graft. He is preparing to go home tomorrow. Mr. J. expresses that he feels unprepared to cook heart-healthy foods. The nurse sits with Mr. J. and reviews the heart-healthy nutrition plan, asking him to identify which foods would be appropriate for him to eat. What type of nursing intervention is the nurse engaging in? Coordinating intervention Educational intervention Supervisory intervention Supportive intervention

Supervisory intervention The nurse is supervising the client's skill performance with regard to assuming responsibility for the self-management of his diet.

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? The client's condition Time and resources Finances of the client Feedback from the family

Finances of the client

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? Registered nurse A senior nursing student present for clinical Licensed practical nurse Nursing assistant

Nursing assistant

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? "I will report your concerns to the nurse manager." "I will discuss your concerns with the night nurse." "You should always speak up if you have any questions about your care." "You always have the right to refuse any medication or treatment."

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

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? Ask the client to verbalize the medication regimen and diet modifications required. Ask the nutritionist to give the client strict meal plans to follow. Ask the gastroenterologist to explain the treatment plan to the client and family again. Refer the client to available community resources and support groups.

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

The nurse is caring for Mr. H., a 35-year-old man who is hospitalized following a motorcycle accident. He has a traumatic brain injury. The nurse is working with Mr. H. on self-care behaviors. The following would help the nurse to assess the success of the nursing interventions except which of the following? Model self-care behaviors for the client. Collect data on the number of self-care activities performed that day. Check with the client to ensure personal goals are met. Ask client to discuss his goals for the day at the start of the shift.

Model self-care behaviors for the client. This question asks specifically about evaluation. Modeling self-care behaviors is an intervention, not an evaluation or assessment technique. When considering the responses, first check for sentence structure. Only one of the choices contains the three elements of the nursing diagnosis: the diagnostic label, the related factors, and the defining characteristics. The question asks for an actual diagnosis; this eliminates any risk, wellness, or potential diagnoses.

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? Nursing assistant who is a nursing student Licensed practical nurse A senior nursing student present for clinical Registered nurse

Nursing assistant who is a nursing student The nurse should avoid delegating this client to the nursing assistant who is a nursing student. Suctioning and the associated evaluation of the client would be within the scope of practice of the registered nurse, licensed practical nurse, and the senior nursing student present for clinical.

The emergency room has a strict protocol regarding IM (intramuscular) injection technique. A nurse working in the emergency room has learned of a new technique to decrease pain with IM injections and would like to use it. What is the most appropriate way for the nurse to implement the technique? Petition to change the protocol based on the new evidence. Ask the ER physician to order IM injections with the new technique. Begin using the technique to determine if it is effective. Research the protocols at other area emergency rooms.

Petition to change the protocol based on the new evidence.

Which nursing intervention is appropriate for a risk nursing diagnosis? Select all that apply. Monitor the client's status. Promote higher level wellness. Reduce or eliminate risk factors. Prevent the problem. Collect additional data to rule out the diagnosis.

Prevent the problem. Reduce or eliminate risk factors. Monitor the client's status.

A nurse documents the diagnosis of Risk for Imbalanced Nutrition: More Than Body Requirements for a client who is hospitalized. What is the priority goal of interventions for a risk diagnosis? Prevention of an actual problem Promote higher level wellness Collect additional data Reduce or eliminate contributing factors

Prevention of an actual problem

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 Developmental stage Current standards of care Research findings

Psychosocial background

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 the priority? Prioritize evaluation of care. Reassess client's needs. Differentiate between subjective and objective data. Document nursing care.

Reassess client's needs. Competence in intellectual, interpersonal, and technical skills is required to carry out the implementation phase. Nurses can delegate parts of the plan of care to other members of the health care team, but the registered nurse (RN) maintains accountability for the supervision and evaluation of these people. The activities of implementation include: (a) reassess, (b) set priorities, (c) perform nursing interventions, (d) record nursing actions.

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. The client discusses the specifics of what was taught during the session. The client is able to answer the nurse's questions. The client verbalizes understanding of the instructions. The client tells the nurse that his wife will handle his care. The client asks the nurse to repeat the instructions.

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.

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's oxygen saturation level increases. The client's family asks if the client is going to be okay. The client states, "I can breathe easier now." The client is watching television.

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

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? The nurse should inform the charge nurse that she does not have the experience to properly care for this client. The nurse should request that the blood transfusions be delayed until the next shift. The nurse should recognize the necessity of the assignment and provide care to the best of her ability. The nurse should ask another nurse who was previously assigned to the client for instruction.

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

The nurse assigned to care for a client that has received a sedative has asked the unlicensed assistive personnel (UAP) to help the client to the toilet. The nurse demonstrates proper delegation skills by performing which actions? (Select all that apply.) transferring accountability and responsibility for the client to the UAP confirming the UAP has successfully passed this skill competency confirming that the UAP has repeatedly completed similar tasks being available for questions from the UAP giving a report on the client to the UAP and answering questions

confirming the UAP has successfully passed this skill competency being available for questions from the UAP giving a report on the client to the UAP and answering questions confirming that the UAP has repeatedly completed similar tasks

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. limiting the amount of reimbursement allowed for nursing services allocating nursing resources teaching decision making communicating nursing to non-nurses allowing the use of multiple systems of nomenclature developing information systems

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

A client being treated with chemotherapy for breast cancer tells the nurse that she no longer wants to receive the medication because of the overwhelming nausea and vomiting. What is the best response by the nurse? "I will consult with the health care provider to see how the nausea and vomiting can be prevented." "I am going to discuss this with your family members." "I am going to have to tell the health care provider that you are refusing treatment." "Are you aware of what will happen to you if you stop taking the chemotherapy?"

"I will consult with the health care provider to see how the nausea and vomiting can be prevented."

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? "I will not work tomorrow because I want to have a day off." "I will work tomorrow because short-staffing is dangerous for the clients." "I will work tomorrow because the other nurses need my help." "I will not work tomorrow because I would be a danger to my clients."

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

The nurse is preparing to administer oxygen 3 L/min via nasal cannula. The nursing student asks, "What type of nursing intervention is oxygen administration?" What is the best response by the nurse? "Oxygen administration is an independent nursing intervention, because nurses have the necessary skill to administer oxygen." "Oxygen administration is a dependent nursing intervention, as oxygen is considered a drug that requires a physician's order." "Oxygen administration is an interdependent intervention, because physicians, nurses, and respiratory therapists have the necessary skill to administer oxygen." "Oxygen administration is a collaborative nursing intervention, because it is ordered by the respiratory therapist."

"Oxygen administration is a dependent nursing intervention, as oxygen is considered a drug that requires a physician's order."

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

Assess for bladder distention.

As part of the plan of care, a nurse administers scheduled pain medication to a postoperative client with a pain level of 6 on a 0 to 10 scale. Which action best represents the next step in the nursing process? Administer p.r.n. pain medications in 60 minutes. Ambulate the client in 20 minutes. Assess pain level in 30 minutes. Assess respirations in 40 minutes.

Assess pain level in 30 minutes.

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? Ask if the client would like to speak with a spiritual adviser. Research other treatment options available for the client. Collaborate with other disciplines to plan end-of-life care for the client. Remind the client that positive thoughts are essential for recovery.

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

The client has a diagnosis of Risk for Injury related to falls. How would the nurse know if the intervention was successful? The client verbalizes risks for injury. The client is taught safety precautions. The client calls for assistance to get out of bed. The client is free of falls.

The client is free of falls.

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." "I can learn about evidence-based practice by reading professional nursing journals." "Nursing interventions should be supported by a sound scientific rationale." "The Agency for Healthcare Research and Quality is a resource for evidence-based practice."

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

A client with diabetes who has been closely following the prescribed plan of care for over a year is being seen at an outpatient setting. 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? "Should I arrange for a home health nurse to coordinate your care?" "It seems like you are having difficulty with your care regimen." "It is extremely important to your health to strictly follow your plan of care." "Should I instruct your family to do the glucose checks for you?"

"It seems like you are having difficulty with your care regimen."

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

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

Which examples of nursing actions involve direct care of the client? Select all that apply. A nurse massages the back of a client while performing a skin assessment. A nurse counsels a young family who is interested in natural family planning. A nurse arranges for a consultation for a client who has no health insurance. A nurse helps a client in hospice fill out a living will form. A nurse arranges for physical therapy for a client who had a stroke.

A nurse counsels a young family who is interested in natural family planning. A nurse massages the back of a client while performing a skin assessment. A nurse helps a client in hospice fill out a living will form. A direct care intervention is a treatment performed through interaction with the client(s). Direct care interventions include both physiologic and psychosocial nursing actions, and include both the "laying of hands" actions and those that are more supportive and counseling in nature. An indirect care intervention is a treatment performed away from the client but on behalf of a client or group of clients. Indirect care interventions include nursing actions aimed at management of the client care environment and interdisciplinary collaboration.

The nursing is caring for several clients. Which intervention can the nurse direct the unlicensed assistive personnel (UAP) to perform? Feed a client who is eating for the first time following an ischemic stroke. Bathe a client with stable angina who has a continuous IV infusing. Assist the client who is ambulating the first time since hip replacement surgery. Take the vital signs of the client who just returned from surgery.

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

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? Notify the physician of the client's refusal. Discuss with the client the reasons for declining surgery. Ask the client to discuss the decision with family members. Review with the client the risks and benefits of surgery.

Discuss with the client the reasons for declining surgery.

A client being treated for myasthenia gravis at home tells the nurse, "This medicine is so expensive. I have only been taking half of what the doctor ordered." How would the nurse most effectively meet this client's need? Inform the physician of the need to prescribe a less expensive medication for the client's condition. Instruct the client that some pharmaceutical companies have programs to help with medication expenses. Reinforce to the client and family the necessity of taking all medication as ordered to stabilize the client's condition. Collaborate with other disciplines to determine the best way to meet the client's medication requirements.

Collaborate with other disciplines to determine the best way to meet the client's medication requirements. In order to meet the client's needs, it is most important to involve other disciplines in the client's care to utilize all available resources. Reinforcing the importance of the medication does not solve the financial problem. It may be necessary for the physician to prescribe a less expensive medication, but other options should be considered to address the holistic needs of the client. Some pharmaceutical companies have programs to help with medication expenses, but the client will need information in order to apply for the programs.

A staff nurse has asked the nursing student to perform an intervention that the nursing student has not been trained to perform. What is the appropriate approach for the nursing student to take? Delegate the intervention to unlicensed assistive personnel. Review the procedure in the procedure manual before performing the intervention. Perform the procedure and inform the instructor of the results. Consult with the nursing instructor before performing the procedure.

Consult with the nursing instructor before performing the procedure.

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? Surveillance Supportive Technical Coordinating

Coordinating

Delegating responsibilities is one of the tools the nurse uses during client care. Which statement is appropriate when delegating? Provide appropriate supervision when delegating tasks. Delegate tasks that involve minimal risk. Delegate correctly to avoid questions being asked. Delegate tasks that follow the individual's scope of practice. Provide feedback after task is completed.

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.

A nurse is preparing to educate a client about self-care after a cataract surgery. Which of the following would the nurse do first? Determine the client's willingness to follow the regimen. Instruct the unlicensed assistive personnel (UAP) on what to teach the client. Ensure physician approval for the education plan. Identify changes from the baseline.

Determine the client's willingness to follow the regimen.

The nurse has administered pain medication to a client with a fractured femur. One hour later, the client reports relief of pain. What is the nurse's next action? Document the effectiveness of the intervention. Plan to decrease the pain medication next time. Instruct the client to use imaging and slow breathing. Instruct the client to wait as long as possible to ask for medication.

Document the effectiveness of the intervention.

The RN is orienting a new nurse who suggests a different way to perform a procedure. What is the RN's most appropriate reaction? Consult with another experienced nurse for input. Remind the new nurse of the facility's policy and procedure. Listen to the new nurse's suggestion and evaluate its usefulness. Consult with the client's physician for appropriateness.

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

Which nursing actions reflect the implementing step of nursing process? (Select all that apply.) Using evidence-based interventions individualized for the client Selecting culturally sensitive nursing interventions Providing health education to reduce health risks Referring the client to community resources, when necessary Determining the client's response to nursing interventions

Providing health education to reduce health risks Referring the client to community resources, when necessary Using evidence-based interventions individualized for the client

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. Technical Psychosocial Coordinating Physical Supportive

Psychosocial Supportive Physical Supportive nursing interventions emphasize the use of communication skills, relief of spiritual distress, and caring behaviors such as touch. Some clients and families respond to stress by joking, teasing, or laughing about it. They may use humor as a way to relieve stress. A client may say jokingly, "Gee, my arm must be target practice for everyone learning how to draw blood." Technical is supporting the client by using medical jargon to explain medical procedures. Coordinating to bringing in additional resources for the client.

A busy nurse is working with an unlicensed assistive personnel (UAP). What tasks can the nurse appropriately delegate to the UAP? Mark all that apply. Assist the client to the bedside commode. Assess the client's need for education. Administer routine oral medications. Assess the client's risk for pressure ulcers. Record the client's intake and output.

Record the client's intake and output. Assist the client to the bedside commode.

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? Reinforce the instructions for the treatment regimen to the client. Interview the family to determine if the client is giving accurate information. Inform the client that the blood pressure medication will have to be changed. Report the findings to the physician for further plans.

Report the findings to the physician for further plans.

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 severity of the client's disease Medications used to treat diabetes mellitus Risk factors and prevention of diabetes mellitus The cellular metabolism of glucose

Risk factors and prevention of diabetes mellitus

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? Surveillance intervention Psychomotor intervention Maintenance intervention Educational intervention

Surveillance intervention

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 appropriate first action? The nurse should address the concern with the surgeon. The nurse should address the concern with the hospital ethics committee. The nurse should address the concern with the hospital attorney. The nurse should address the concern with the client's family.

The nurse should address the concern with the surgeon.

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. providing routine discharge instructions related to infant care assisting the client with personal hygiene needs and ambulation transporting the infant to the mother's room according to hospital policy initial assessment of the mother after birth of the infant assisting and teaching the client to breastfeed the infant

assisting the client with personal hygiene needs and ambulation transporting the infant to the mother's room according to hospital policy

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

auscultating of bilateral lung sounds

Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? ambulation of the client with a history of falls for the first time after surgery insertion of a urinary catheter in a client with benign prostatic hypertrophy bed bath for the newly-admitted client who has multiple skin lesions preparation of insulin for the diabetic client with elevated blood glucose

bed bath for the newly-admitted client who has multiple skin lesions The safest delegation is to have the UAP bathe the client with skin lesions and report any abnormal findings to the nurse. Preparing insulin is outside of the UAPs scope of practice. The UAP may have the skills to insert an indwelling catheter and ambulate clients, but the clients involved each have qualifiers that complicate the tasks.

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

help the client achieve optimal levels of health.

The registered nurse (RN) is delegating the task of assisting a post-operative client to the bathroom to the unlicensed assistive personnel (UAP). The nurse witnessed the UAP correctly perform the task on previous occasions, and knows the UAP is competent to perform the task. The nurse has communicated how to get the client out and back into bed, and told the UAP not to allow the client to bear weight on the left leg. The nurse validated that the activity was completed and gave the UAP feedback. Which delegation guideline was omitted by the nurse? right supervision right task right circumstance right person

right circumstance

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: nursing interventions. collaborative orders. standing orders. protocols.

standing orders.

Which nursing intervention is most likely to be allowed within the parameters of a protocol or standing order? Administering a beta-adrenergic blocker to a new client whose blood pressure is high on admission assessment Administering a glycerin suppository to a constipated client who has not responded to oral stool softeners Changing a client's advance directive after his prognosis has significantly worsened Changing a client's intravenous (IV) fluid from normal saline to 5% dextrose

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

The nurse is caring for a client who does not speak the same language. The unlicensed assistive personnel (UAP) speaks the same language as the client. What parts of communicating with the client could the nurse appropriately delegate to the UAP? Select all that apply. Provide education to the client, including discharge instructions. Interview the client as part of the admission assessment. Orient the client and family to the room, including the call light button. Counsel the client about making adjustments to a new medical condition. Ask the client questions regarding personal care needs. Demonstrate and teach new caregiving procedures to the family.

Ask the client questions regarding personal care needs. Orient the client and family to the room, including the call light button.

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

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

One hour after receiving blood pressure medication, the client reports feeling lightheaded and dizzy. What is the nurse's first action? Assess the client's blood glucose level. Assess the client's blood pressure. Convey the client's report of dizziness to the physician. Review the results of laboratory testing.

Assess the client's blood pressure.

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

Assess the client's response to the ambulation.

The home health nurse caring for a client with limited eyesight notes that the client's route to the bathroom is cluttered. What is the most effective way for the nurse to ensure the client's long-term safety? Assign a home health aide to perform housekeeping duties. Instruct the client about the need to keep the walkway to the bathroom clear. Assist the client to identify strategies to promote safety in the home. Remove all the cluttered objects from the pathway to the client's bathroom.

Assist the client to identify strategies to promote safety in the home.

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. Collecting a database to enable an effective plan of care Modifying the client plan of care Developing client outcomes and goals Performing an initial assessment of the client Measuring how well the client has achieved client goals Collecting additional client data

Collecting additional client data Modifying the client plan of care

After instituting interventions to increase oxygenation, the client shows no signs of improvement. What is the nurse's priority action? Determine the client's code status in case of an emergency. Document the interventions and the result. Reassess the client for improvement in 30 minutes. Communicate with the physician for additional orders.

Communicate with the physician for additional orders.

Nurse Sanchez is a community health nurse in a largely Hispanic community. She has noticed that a large percentage of her clients with type 2 diabetes struggle to find food choices that are a compatible with the cooking style of their culture. Nurse Sanchez decides to organize a cooking class to demonstrate to clients with type 2 diabetes how to prepare culturally appropriate foods. Nurse Sanchez's actions could be labeled as what types of nursing interventions? Select all that apply. Psychosocial intervention Educational intervention Supportive intervention Supervisory intervention

Educational intervention Psychosocial intervention Supervisory intervention

The nurse is discussing dietary options with a client who is upset due to the inability of not being able to have foods previously enjoyed. The nurse states "You may not be able to have steak but you can have grilled salmon or grilled chicken. Which do you prefer?" What is the purpose for giving the client an option? Allowing the client to have options will help with adherence to the plan The client must eat hospital food that is good for him. The food choices are available in the menu. Giving the client options demonstrates active participation in care

Giving the client options demonstrates active participation in care

A student nurse has reported for a clinical preceptorship in a hospital and has been reassigned from the medical surgical unit to a pediatric unit. The student nurse has never worked with pediatric clients. Which of the following actions should the student nurse take in this situation? Call the board of nursing and report this is an infraction to the nurse practice act. Accept the assignment but inform the supervisor she will only take the clients' vital signs. Inform the supervisor that she cannot accept this assignment because of a lack of experience with pediatric clients. Accept the assignment and assess the clients to see if she will be able to adequately care for them.

Inform the supervisor that she cannot accept this assignment because of a lack of experience with pediatric clients. The correct action in this situation is for the student nurse to inform the supervisor that she cannot accept the assignment since she is not competent working with pediatric clients. The student nurse cannot accept the assignment and only perform vital signs for the clients under her care. The student nurse cannot accept the assignment and then decide that she cannot competently care for the clients. Once the assignment has been accepted the student nurse has accepted responsibility for the clients until the end of her shift. This assignment is not an infraction of the nurse practice act. The student nurse has the option of not accepting the assignment. (less)

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? Notify the physician that the client has required pain medications. Perform additional non-pharmacologic pain interventions. Reassess the client to determine the effectiveness of the interventions. Instruct the client that pain medication is available at regular intervals.

Reassess the client to determine the effectiveness of the interventions.

A nurse in the ICU (intensive care unit) has been assigned to care for a client who was seriously injured during a gang rape. The nurse was raped 6 months ago and feels that she will be too upset to care for the client properly. How should the nurse deal with the assignment? Recognize that she may be faced with this issue again and care for the client. Recognize her limitations and ask another nurse to assist her if she becomes too emotional. Recognize her limitations and ask for another nurse to be assigned. Recognize the issue and care for the client to the best of her ability.

Recognize her limitations and ask for another nurse to be assigned.

Which role is a responsibility of the nurse in the nurse-health care team relationship? Select all that apply. Provide creative leadership to make the nursing unit a satisfying and challenging place to work. Coordinate the inputs of the multidisciplinary team into a comprehensive plan of care. Educate the family to be informed and assertive consumers of health care. Support the nursing care given by other nursing personnel. Serve as a liaison between the client and family and the health care team.

Serve as a liaison between the client and family and the health care team. Coordinate the inputs of the multidisciplinary team into a comprehensive plan of care.

The client reports right knee pain of 6/10 on the pain scale and requests for medication. The nurse assesses and flushes the IV site. Which type of intervention skill is the nurse using? Intellectual skill Mechanical skill Technical skill Interpersonal skill

Technical skill Technical skills are used to carry out treatments and procedures. Nurses learn the specific skills through clinical practice. Technical competence means being able to use equipment, machines, and supplies in a particular specialty. (less)

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

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

The nursing team, consisting of a nurse and experienced unlicensed assistive personnel, have worked well together for the past year. One of the nurse's assigned clients is injured in a fall and requires uninterrupted attention. 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. The nurse delegated too many tasks to the unlicensed assistive personnel. The nurse failed to validate the UAP's knowledge and skill to perform the tasks. The nurse delegated tasks to the UAP that are outside the scope of that person's preparation.

The nurse failed to communicate clear instructions regarding what constitutes a low blood pressure. The nurse failed to communicate clear instructions to the UAP. The delegated tasks are not too numerous and are within the scope of an 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.

When caring for a client in the emergency room who has presented with symptoms of a (MI) myocardial infarction, the nurse orders laboratory tests and administers medication to the client before the physician has examined the client. In order for the nurse to be operating within the nurse's scope of practice, what conditions must be present? The nurse is ordering what the physician usually orders. The nurse is operating under standing orders for clients with MIs. The nurse is experienced in the needs of clients with MIs. The nurse is utilizing the standards of care for clients with MIs.

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

Which examples 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. The unlicensed assistive personnel can verbalize what information is to be reported to the nurse. The unlicensed assistive personnel evaluates the client's response after implementing the task, then reports to the nurse. The nurse seeks input from the unlicensed assistive personnel in planning the client's care for the shift. Instructions have been clearly communicated by the nurse to the unlicensed assistive personnel (UAP).

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 (UAP). The unlicensed assistive personnel can verbalize what information is to be reported to the nurse.

Nurses use the Nursing Outcomes Classification when choosing nursing goals for clients. What are the goals of the research that is behind the Nursing Outcomes Classification (NOC)? Select all that apply. To ensure appropriate reimbursement for nursing services To evaluate the validity and usefulness of the classification in clinical field testing To communicate nursing to non-nurses To identify, label, and validate nursing-sensitive client outcomes and indicators To teach decision making 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 To define and test measurement procedures for the outcomes and indicators

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. to determine what nursing actions can be delegated demonstration of the impact of nurses creation of a standardized language to justify productivity of the nursing staff assistance in determining the cost of services that nurses provide

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