Chapter 18- Implementing

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? Supportive Surveillance Collaborative Maintenance

Surveillance

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? Educational Psychomotor Maintenance Surveillance

Surveillance

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 asks the nurse to repeat the instructions. The client tells the nurse that the client's spouse will handle the care. The client discusses the specifics of what was taught during the session.

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

Which is the priority question for the nurse to consider before implementing a new intervention? Does this treatment make sense for this client? How much experience do I have with this treatment? What equipment do I need? Will I need someone to assist me?

Does this treatment make sense for this client?

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

Risk factors for and prevention of diabetes mellitus

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 male. The client is married. The client is blind. The client is an architect. The client denies the need for education.

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

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. environment and client. logistics and planning. skills and assistance.

equipment and personnel.

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."

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 daughter has been staying with me the past few weeks." "I asked my neighbors to help me with my yard work." "My wife's been gone for about 7 months now." "I sort my medication into an organizer every week."

"My wife's been gone for about 7 months now."

The nurse is preparing a client to be discharged from the surgical unit following abdominal surgery. Which intervention will the nurse use to ensure the client's adherence to proper wound care techniques? Include family members or other caregivers in the education. Delegate teaching to unlicensed assistive personnel (UAP). Provide a video demonstration of abdominal wound care. Document client education prior to discharge from the unit.

Include family members or other caregivers in the education.

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

Nurse case manager

The nurse is coordinating care for a client with continuous pulse oximetry who requires pharyngeal suctioning. To which staff member should the nurse avoid delegating the task of suctioning? registered nurse unlicensed assistive personnel who is in nursing school senior student in nursing school who is present for clinical licensed practical/vocational nurse

unlicensed assistive personnel who is in nursing school

A nurse is providing care to several assigned clients and decides to delegate the task of morning vital signs to unlicensed assistive personnel. The nurse would assume responsibility and refrain from delegating this task for which client? A client with a high fever receiving intravenous fluids, antibiotics, and oxygen An older adult with pneumonia who is being discharged to the son's home tomorrow A middle-aged client who had abdominal surgery 3 days ago and is ambulating in the hall An adult client who is being treated for kidney stones

A client with a high fever receiving intravenous fluids, antibiotics, and oxygen

The nurse has prepared to educate a client about caring for a new colostomy. When the nurse begins the instruction, the client states, "I am not ready to deal with this now. I am feeling overwhelmed." What is the nurse's most appropriate action? Continue the education and remind the client that it is essential to learn self-care. Medicate the client for anxiety and continue the education later. Discontinue the education and attempt at another time. Discontinue the education and ask the client for permission to teach a family member.

Discontinue the education and attempt at another time.

The nurse is caring for a 10-year-old client who is newly diagnosed with a seizure disorder. What variable would alter the nurse's plan for educating the client and parent? The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years. The client expresses a desire to learn how to manage the medication regime. The parents verbalize acceptance of the need to closely monitor their child's condition. The parents have comprehensive insurance coverage for their family's medical care.

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

A nurse who is experienced caring only for well babies is assigned to the neonatal intensive care unit (NICU) because of a shortage of nurses in the NICU. The nurse is assigned to an infant on a ventilator who will require blood transfusions during the shift. What is the nurse's mostappropriate course of action? The nurse should inform the charge nurse that the nurse does not have the experience to properly care for this client. The nurse should ask another nurse who was previously assigned to the client for instruction. 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 the nurse's ability.

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

The client is having difficulty breathing. The respiratory rate is 44 and the oxygen saturation is 89% (0.89 L). The nurse raises the head of the bed and applies oxygen at 3 L/min per nasal cannula. How does the nurse determine the effectiveness of the interventions? Select all that apply. The client's respiratory rate decreases. The client states, "I can breathe easier now." The client's oxygen saturation level increases. The client is watching television. The client's family asks if the client is going to be okay.

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

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

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

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? Remind the client that the client is responsible for the client's own health care decisions. Ask the client whether the client is afraid that the spouse will be angry. Ask the surgeon to wait until the client has had a chance to talk to the spouse. Inform the surgeon that the nurse will not sign the informed consent form.

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

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. Give the visitors instructions to leave in 10 minutes. Ask the client if the client has any questions. Leave written information for the client to read later.

Delay the instruction until the visitors leave.

The nurse is preparing a client for surgery when the client tells the nurse that the client no longer wants to have the surgery. How should the nurse most appropriately respond? Review with the client the risks and benefits of surgery. Ask the client to discuss the decision with family members. Discuss with the client the reasons for declining surgery. Notify the health care provider of the client's refusal.

Discuss with the client the reasons for declining surgery.

The nurse is proceeding through the nursing process in the care of a new client. During the implementation phase, the nurse will most likely accomplish what task? Establish trust and rapport with the client Identify a need for collaborative consults Help the client achieve optimal levels of health Implement the critical pathway for the client

Help the client achieve optimal levels of health

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

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

Which statement best explains why continuing data collection is important? It is difficult to collect complete data in the initial assessment. It is the most efficient use of the nurse's time. It enables the nurse to revise the care plan appropriately. It meets current standards of care.

It enables the nurse to revise the care plan appropriately.

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? Inform the client that it is not necessary to wash hands before vital signs. Reassure the client that the nurse knows when to perform hand hygiene. Praise the client for taking an active role in the client's care. Tell the client that gloves are required for this procedure.

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

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.

Which examples of nursing actions involve direct care of the client? Select all that apply. 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 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.

The nurse is preparing to administer a blood pressure medication to a client. To ensure the client's safety, what is the priority action for the nurse to take? Assess the client's blood pressure to determine if the medication is indicated. Determine the client's reaction to the medication in the past. 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

With which nursing action is the nurse performing a surveillance or monitoring intervention? Auscultating bilateral lung sounds Providing assistance with hygiene Administering a paracetamol tablet Applying therapeutic communication skills

Auscultating bilateral lung sounds

A nurse is developing a plan of care for a client and determines appropriate outcomes and interventions for this client. Which variable would be most appropriate for the nurse to address to ensure that the care plan meets the client's needs? Select all that apply. Client's ability to participate Client's developmental stage Client's cultural background Client's socioeconomic status Client's gender

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

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 Client, health care provider, and hospital director Client, physical therapist, and nursing staff Client, surgeon, and health care provider

Client, family, and health care provider

A nurse is caring for a postoperative client who reports a pain level of 6 on a scale from 1 to 10. After administering the prescribed pain medication, which intervention should the nurse include in the nursing care plan to monitor and evaluate pain? Assess nonpharmacologic modalities used to reduce pain. Implement the ABC guide of pain management. Ambulate the client after administration of pain medication. Review client goals for comfort.

Implement the ABC guide of pain management.

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

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

The nurse has instructed the client in self-catheterization, but the client is unable to perform a return demonstration. What is the nurse's mostappropriate plan of action? Teach the content again utilizing the same method. Reassess the appropriateness of the method of instruction. Revise the plan to include the inclusion of a support group. Report the client's inability to learn to the case manager.

Reassess the appropriateness of the method of instruction.

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

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

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

The client with continuous pulse oximetry who requires pharyngeal suctioning.

Which actions are examples of nursing actions listed in the ANA's Nursing: Scope and Standards of Practice for Standard 5: Implementation? Select all that apply. The nurse demonstrates quality by documenting the application of the nursing process in a responsible, accountable, and ethical manner. The nurse incorporates new knowledge to initiate changes in nursing practice if the desired outcomes are not achieved. The nurse develops expected outcomes that provide direction for the continuity of care. The nurse documents implementation and any modifications, including changes or omissions, of the identified plan. The nurse utilizes community resources and systems to implement the plan. The nurse utilizes evidence-based interventions and treatments specific to the diagnosis or problem.

The nurse documents implementation and any modifications, including changes or omissions, of the identified plan. The nurse utilizes community resources and systems to implement the plan. The nurse utilizes evidence-based interventions and treatments specific to the diagnosis or problem

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 explains each procedure twice to prevent client questions from wasting time. The nurse encourages the client to participate in all treatment decisions as the center of the health care team. The nurse encourages clients to advocate for themselves instead of choosing a trusted family member or friend. The nurse assures the client who questions a medication that it is the right medication prescribed for him or her and administers the medicine.

The nurse encourages the client to participate in all treatment decisions as the center of the health care team.