Chapter 17: Implementing

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." "Even though I do not provide care to clients, my work is very important." "I provide a critical service that is necessary for financial reimbursement." "Moving away from client care is a necessary step to advancing my career."

"I provide indirect care to my clients by coordinating their treatment with other disciplines." Rationale: Nurses can provide direct, indirect, and collaborative care for their clients. A case manager directs interventions on behalf of the client away from the client's bedside. The most appropriate response is "I provide indirect care...". The case manager's response about the work being important does not adequately explain the role of the case manager. The case manager's role in facilitating financial reimbursement is critical, but does not address the nurse manager's role in client care. The case manager is still providing client care.

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 Research findings Current standards of care

Psychosocial background Rationale: The nurse is demonstrating an awareness of the client's psychosocial background, which includes consideration of the client's socioeconomic status. Research findings and current standards of care are examples of nursing variables. Developmental stage is a client variable that addresses the developmental needs of a 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." "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." Rationale: Nursing interventions should be supported by a sound scientific rationale; however, nurses do not need to personally conduct research to establish the rationale for nursing interventions. Nurses can learn about evidence-based practice by reading professional nursing journals, attending nursing workshops, and consulting evidence-based practice resources, such as the Agency for Healthcare Research and Quality.

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 is extremely important to your health to strictly follow your plan of care." "It seems like you are having difficulty with your care regimen." "Should I arrange for a home health nurse to coordinate your care?" "Should I instruct your family to do the glucose checks for you?"

"It seems like you are having difficulty with your care regimen." Rationale: The nurse's open-ended statement acknowledging that the client is having difficulty with the care regimen encourages the client to discuss what has occurred that has caused the client to not manage the diabetes as was previously done. The statement reminding the client that health care is important will discourage the client to freely discuss any problems. A home health nurse or instructions given to the family may be indicated, but not until the client has verbalized the reasons why the care regimen has not been followed.

The nursing is caring for several clients. Which intervention can the nurse direct the unlicensed assistive personnel (UAP) to perform? Take the vital signs of the client who just returned from surgery. 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.

Bathe a client with stable angina who has a continuous IV infusing. Rationale: The nurse can instruct the UAP to bathe the client with stable angina who has a continuous IV infusing. The other clients require the clinical reasoning skills of the nurse to evaluate their response.

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. Identify changes from the baseline. Ensure physician approval for the education plan. Instruct the unlicensed assistive personnel on what to teach the client.

Determine the client's willingness to follow the regimen. Rationale: The prerequisite to health education about self-care after cataract surgery is the client's willingness to follow the regimen. Once a nurse is aware of the client's readiness for learning, the nurse can implement outcome-based education plans. Identifying changes from baseline is important for monitoring interventions. Approval by the physician may not be necessary. Delegating the teaching activity to an unlicensed assistive personnel is inappropriate because it is not within the person's scope of practice.

A nurse is caring for a client with burns. Place the steps in the appropriate order for providing wound care for the client. Use all options. 1Remove old dressing. 6Record color and odor of discharge. 2Assess condition of wound. 3Obtain a culture. 4Open sterile dressing tray. 5Change from clean to sterile gloves.

Remove old dressing. Assess condition of wound. Obtain a culture. Open sterile dressing tray. Change from clean to sterile gloves. Record color and odor of discharge. Rationale:The nursing care plan begins with assessment. After removing the old dressing, the nurse should perform the initial assessment of the wound first and then take a swab stick sample for culture (implementation). Next, the nurse changes the dressing (implementation) of the wound, by first opening the dressing tray and changing from clean to sterile gloves to prevent contamination of the wound. Finally, the nurse documents the findings (documentation). Documentation should occur after the assessment and implementation of care has occurred.

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. 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. Rationale: The nurse should report the findings to the physician so that the treatment regimen can be revised. The client reports following the treatment regimen, so reinforcing the instructions is not indicated. Interviewing the family would indicate to the client that the nurse did not trust the client's report, so this would be inappropriate. The nurse cannot tell the client that the blood pressure medication will have to be changed because that is the physician's decision.

Nursing interventions for the client after prostate surgery include assisting the client to ambulate to the bathroom. The nurse concludes that the client no longer requires assistance. What is the nurse's best action? Revise the care plan to allow the client to ambulate to the bathroom independently. Continue assisting the client to the bathroom to ensure the client's safety. Consult with the physical therapist to determine the client's ability. Instruct the client's family to assist the client to ambulate to the bathroom.

Revise the care plan to allow the client to ambulate to the bathroom independently. Rationale: The intervention of assisting the client to the bathroom is no longer indicated, so the nurse would appropriately revise the care plan to discontinue that intervention. A consult with a physical therapist is not necessary to verify the nurse's independent assessment. If the client is safe to ambulate to the restroom independently, it is not necessary for the family to assist.

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? Algorithm Standing orders Protocol Order set

Standing orders Rationale: Standing orders allow the nurse to initiate actions that ordinarily require the order of a physician, such as administering naloxone. An algorithm is a binary decision tree that guides stepwise assessment and intervention for a high-risk subgroup of clients. A protocol is a written plan that details nursing activities to be executed in specific situations. An order set is a preprinted set of provider orders that expedite the provider order process.