Implementation/Interventions-1

Which of the following is the best guarantee that the patient's priority needs are met? a. Checking with the relative of the patient b. Preparing a nursing care plan in collaboration with the patient c. Consulting with the physician d. Coordinating with other members of the team

(B) Preparing a nursing care plan in collaboration with the patient The best source of information about the priority needs of the patient is the patient himself. Hence using a nursing care plan based on his expressed priority needs would ensure meeting his needs effectively.

The RN employed in a long-term care facility is planning assignments for the clients on a nursing unit. The RN needs to assign four clients and has a licensed practical (vocational) nurse and three nursing assistants on a nursing team. Which of the following clients would the nurse most appropriately assign to the licensed practical (vocational) nurse? 1. The client who requires a bed bath. 2. An older client requiring frequent ambulation. 3. A client who requires a 24-hour urine collection. 4. A client with an abdominal wound requiring wound irrigations and dressing changes every 3 hours.

4. When delegating nursing assignments, the nurse needs to consider the skills and educational level of the nursing staff. Collecting a 24-hour urine sample, giving a bed bath, and assisting with frequent ambulation can be provided most appropriately by the nursing assistant. The licensed practical (vocational) nurse is skilled in wound irrigations and dressing changes and most appropriately would be assigned to the client who needs this care.

The nurse calls the physician regarding a new medication order because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the physician and the medication is due to be administered. Which action should the nurse take? 1. Contact the nursing supervisor. 2. Administer the dose prescribed. 3. Hold the medication until the physician can be contacted. 4. Administer the recommended dose until the physician can be located.

1. If the physician writes an order that requires clarification, the nurse's responsibility is to contact the physician for clarification. If there is no resolution regarding the order because the physician cannot be located or because the order remains as it was written after talking with the physician, the nurse then should contact the nurse manager or nursing supervisor for further clarification as to what the next step should be. Under no circumstances should the nurse proceed to carry out the order until obtaining clarification.

The RN has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client will the RN plan to care for first? 1. A client who is ambulatory. 2. A client scheduled for physical therapy at 1 pm 3. A client with a fever who is diaphoretic and restless. 4. A postoperative client who has just received pain medication.

3. The RN would plan to care for the client who has a fever and is diaphoretic and restless first because this client's needs are the priority. Waiting for pain medication to take effect before providing care to the postoperative client is best. The client who is ambulatory and the client scheduled for physical therapy later in the day do not have priority needs related to care.

The RN is planning the client assignments for the day. Which of the following is the most appropriate assignment for the nursing assistant? 1. A client requiring colostomy irrigation. 2. A client receiving continuous tube feedings. 3. A client who requires urine specimen collections. 4. A client with difficulty swallowing food and fluids.

3. The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for a nursing assistant would be to care for the client who requires urine specimen collections. The nursing assistant is skilled in this procedure. Colostomy irrigations and tube feedings are not performed by unlicensed personnel. The client with difficulty swallowing food and fluids is at risk for aspiration.

Katherine is a young Unit Manager of the Pediatric Ward. Most of her staff nurses are senior to her, very articulate, confident and sometimes aggressive. Katherine feels uncomfortable believing that she is the scapegoat of everything that goes wrong in her department. Which of the following is the best action that she must take? A. Identify the source of the conflict and understand the points of friction B. Disregard what she feels and continue to work independently C. Seek help from the Director of Nursing D. Quit her job and look for another employment.

A) Identify the source of the conflict and understand the points of friction This involves a problem solving approach, which addresses the root cause of the problem.

20. When calling the nurse consultant about a difficult client-centered problem, the primary nurse is sure to report the following: 1. Length of time the current treatment has been in place. 2. The spouse's reaction to the client's dressing change. 3. Client's concern about the current treatment. 4. Physician's reluctance to change the current treatment plan.

A. This gives the consulting nurse facts that will influence a new plan. (b, c, and d. These are all subjective and emotional issues/conclusions about the current treatment plan and may cause a bias in the decision of a new treatment plan by the nurse consultant.)

4. A client centered goal is a specific and measurable behavior or response that reflects a client's: 1. Desire for specific health care interventions 2. Highest possible level of wellness and independence in function. 3. Physician's goal for the specific client. 4. Response when compared to another client with a like problem.

B

19. A client's wound is not healing and appears to be worsening with the current treatment. The nurse first considers: 1. Notifying the physician. 2. Calling the wound care nurse 3. Changing the wound care treatment. 4. Consulting with another nurse.

B. Calling in the wound care nurse as a consultant is appropriate because he or she is a specialist in the area of wound management. Professional and competent nurses recognize limitations and seek appropriate consultation. (a. This might be appropriate after deciding on a plan of action with the wound care nurse specialist. The nurse may need to obtain orders for special wound care products. c. Unless the nurse is knowledgeable in wound management, this could delay wound healing. Also, the current wound management plan could have been ordered by the physician. d. Another nurse most likely will not be knowledgeable about wounds, and the primary nurse would know the history of the wound management plan.)

Which of the following activities is NOT done by a primary nurse? A. Collaborates with the physician B. Provides care to a group of patients together with a group of nurses C. Provides care for 5-6 patients during their hospital stay. D. Performs comprehensive initial assessment

(B) Provides care to a group of patients together with a group of nurses This function is done in team nursing where the nurse is a member of a team that provides care for a group of patients.

When Harry uses team nursing as a care delivery system, he and his team need to assess the priority of care for a group of patients, which of the following should be a priority? a. Each patient as listed on the worksheet b. Patients who needs least care c. Medications and treatments required for all patients d. Patients who need the most care

(D) Patients who need the most care In setting priorities for a group of patients, those who need the most care should be number-one priority to ensure that their critical needs are met adequately. The needs of other patients who need less care ca be attended to later or even delegated to assistive personnel according to rules on delegation.

The nurse is giving a bed bath to an assigned client when a nursing assistant enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. The appropriate nursing action is which of the following? 1. Finish the bed bath and then administer the pain medication to the other client. 2. Ask the nursing assistant to find out when the last pain medication was given to the client. 3. Ask the nursing assistant to tell the client in pain that medication will be administered as soon as the bed bath is complete. 4. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.

4. The nurse is responsible for the care provided to assigned clients. The appropriate action in this situation is to provide safety to the client who is receiving the bed bath and prepare to administer the pain medication. Options 1 and 3 delay the administration of medication to the client in pain. Option 2 is not a responsibility of the nursing assistant.

1. Once a nurse assesses a client's condition and identifies appropriate nursing diagnoses, a: 1. Plan is developed for nursing care. 2. Physical assessment begins 3. List of priorities is determined. 4. Review of the assessment is conducted with other team members.

A

5. For clients to participate in goal setting, they should be: 1. Alert and have some degree of independence. 2. Ambulatory and mobile. 3. Able to speak and write. 4. Able to read and write.

A

2. Planning is a category of nursing behaviors in which: 1. The nurse determines the health care needed for the client. 2. The Physician determines the plan of care for the client. 3. Client-centered goals and expected outcomes are established. 4. The client determines the care needed.

B

24.The RN has received her client assignment for the day-shift. After making the initial rounds and assessing the clients, which client would the RN need to develop a care plan first? 1. A client who is ambulatory. 2. A client, who has a fever, is diaphoretic and restless. 3. A client scheduled for OT at 1300. 4. A client who just had an appendectomy and has just received pain medication.

B

17. When developing a nursing care plan for a client with a fractured right tibia, the nurse includes in the plan of care independent nursing interventions, including: 1. Apply a cold pack to the tibia. 2. Elevate the leg 5 inches above the heart. 3. Perform range of motion to right leg every 4 hours. 4. Administer aspirin 325 mg every 4 hours as needed.

B. This does not require a physician's order. (A & D require an order; C is not appropriate for a fractured tibia)

10. Collaborative interventions are therapies that require: 1. Physician and nurse interventions. 2. Nurse and client interventions. 3. Client and Physician intervention. 4. Multiple health care professionals.

D

21. The primary nurse asked a clinical nurse specialist (CNS) to consult on a difficult nursing problem. The primary nurse is obligated to: 1. Implement the specialist's recommendations. 2. Report the recommendations to the primary physician. 3. Clarify the suggestions with the client and family members. 4. Discuss and review advised strategies with CNS.

D. Because the primary nurse requested the consultation, it is important that they communicate and discuss recommendations. The primary nurse can then accept or reject the CNS recommendations. (a. Some of the recommendations may not be appropriate for this client. The primary nurse would know this information. A consultation requires review of the recommendations, but not immediate implementation. b. This would be appropriate after first talking with the CNS about recommended changes in the plan of care and the rationale. Then the primary nurse should call the physician. c. The client and family do not have the knowledge to determine whether new strategies are appropriate or not. Better to wait until the new plan of care is agreed upon by the primary nurse and physician before talking with the client and/or family.)

Harry is a Unit Manager I the Medical Unit. He is not satisfied with the way things are going in his unit. Patient satisfaction rate is 60% for two consecutive months and staff morale is at its lowest. He decides to plan and initiate changes that will push for a turnaround in the condition of the unit. Which of the following actions is a priority for Harry? a. Call for a staff meeting and take this up in the agenda. b. Seek help from her manager. c. Develop a strategic action on how to deal with these concerns. d. Ignore the issues since these will be resolved naturally.

(A) Call for a staff meeting and take this up in the agenda. This will allow for the participation of every staff in the unit. If they contribute to the solutions of the problem, they will own the solutions; hence the chance for compliance would be greater.

Stephanie delegates effectively if she has authority to act, which is BEST defined as: a. having responsibility to direct others b. being accountable to the organization c. having legitimate right to act d. telling others what to do

(C) having legitimate right to act Authority is a legitimate or official right to give command. This is an officially sanctioned responsibility

performance appraisal consists of all the following activities EXCEPT: A. Setting specific standards and activities for individual performance. B. Using agency standards as a guide. C. Determine areas of strength and weaknesses D. Focusing activity on the correction of identified behavior.

(D) Focusing activity on the correction of identified behavior. Performance appraisal deal with both positive and negative performance; is not meant to be a fault-finding activity

Kathleen knows that one of her staff is experiencing burnout. Which of the following is the best thing for her to do? A. Advise her staff to go on vacation. B. Ignore her observations; it will be resolved even without intervention C. Remind her to show loyalty to the institution. D. Let the staff ventilate her feelings and ask how she can be of help.

(D) Let the staff ventilate her feelings and ask how she can be of help. Reaching out and helping the staff is the most effective strategy in dealing with burn out. Knowing that someone is ready to help makes the staff feel important; hence her self-worth is enhanced.

The nurse has just assisted a client back to bed after a fall. The nurse and physician have assessed the client, and have determined that the client is not injured. After completing the incident report, the nurse should take which action next? 1. Reassess the client. 2. Conduct a staff meeting to describe the fall. 3. Document in the nurse's notes that an incident report was completed. 4. Contact the nursing supervisor to update information regarding the fall.

1. The client's fall should be treated as private information and shared on a "need to know" basis. Communication regarding the event should involve only those participating in the client's care. An incident report is a problem-solving document; however, its completion is not documented in the nurse's notes. If the nursing supervisor has been made aware of the incident, the supervisor will contact the nurse if status update is desired. After a client's fall, the nurse must frequently reassess the client, because potential complications do not always appear immediately after the fall.

A nurse in a newborn nursery receives a telephone call to prepare for the admission of a 43-week gestation newborn infant with Apgar scores of 1 and 4. In planning for admission of this infant, the nurse's highest priority should be to: 1. Turn on the apnea and cardiorespiratory monitors. 2. Connect the resuscitation bag to the oxygen outlet. 3. Set up the intravenous line with 5% dextrose in water. 4. Set the radiant warmer control temperature at 97.6F.

2. The highest priority on admission to the nursery for a newborn with a low Apgar scores is the airway, which would involve preparing respiratory resuscitation equipment. The remaining options are also important, although they are of lower priority. The newborn infant will be placed on an apnea and cardiorespiratory monitor. Setting up an intravenous line with 5% dextrose in water would provide circulatory support. The radiant warmer will provide an external heat source, which is necessary to prevent further respiratory distress.

The nurse manager is planning the clinical assignments for the day and avoids assigning which staff member to the client with herpes zoster? 1. The nurse who never had roseola. 2. The nurse who never had mumps 3. The nurse who never had chickenpox. 4. The nurse who never had German measles.

3. Herpes zoster (shingles) is caused by a reactivation of the varicella-zoster virus, the causative virus of chickenpox. Individuals who have not been exposed to the varicella-zoster virus are susceptible to chickenpox. Health care workers who are unsure of their immune status should have varicella titers done before exposure to a person with herpes zoster. Options 1, 2, and 4 are unrelated to the herpes zoster virus.

A nurse who works on the night shift enters the medication room and finds a co-worker with a tourniquet wrapped around the upper arm. The co-worker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. The appropriate initial action by the nurse is which of the following? 1. Call security. 2. Call the police. 3. Call the nursing supervisor. 4. Lock the co-worker in the medication room until help is obtained.

3. Nurse practice acts require reporting impaired nurses. The board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision of the impaired nurse. This incident needs to be reported to the nursing supervisor, who will then report to the board of nursing and other authorities, such as the police, as required. The nurse may call security if a disturbance occurs, but no information in the question supports this need, and therefore this is not the initial action. Option 4 is an inappropriate and unsafe action.

The nurse employed in a hospital is waiting to receive a report form the laboratory via the fax machine. The fax machine activates and the nurse expects the report but instead receives a sexually oriented photograph. The appropriate initial nursing action is to: 1. Call the police. 2. Cut up the photograph and throw it away. 3. Call the nursing supervisor and report the incident. 4. Call the laboratory and ask for the individual's name that sent the photograph.

3. Sexual harassment in the workplace is prohibited by state and federal laws. Sexually suggestive jokes, touching, pressuring a co-worker for a date, and open displays of or transmitting sexually oriented photographs or posters are examples of conduct that could be considered sexual harassment by another worker. If the nurse believes that he or she is being subjected to unwelcome sexual conduct, these concerns should be reported to the nursing supervisor immediately. Option 1 is unnecessary at this time. Options 2 and 4 are not appropriate initial actions.

The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds a client lying on the floor. The nurse performs a thorough assessment, assists the client back to bed, notifies the physician of the incident, and completes an incident report. Which of the following should the nurse document on the incident report? 1. The client fell out of bed. 2. The client climbed over the side rails. 3. The client was found lying on the floor. 4. The client became restless and tried to get out of bed.

3. The incident report should contain the client's name, age, and diagnosis. The report should contain a factual description of the incident, any injuries experienced by those involved, and the outcome of the situation. Option 3 is the only option that describes the facts as observed by the nurse. Options 1, 2, and 4 are interpretations of the situation and are not factual information as observed by the nurse.

The nurse has just obtained a unit of blood from the blood bank to transfuse into a client as ordered. Before preparing the blood for transfusion, the nurse next looks for which of the following members of the health care team to assist in checking the unit of blood? 1. Phlebotomist. 2. Medical student. 3. Registered nurse. 4. Blood bank technician.

3. Two registered nurses (RNs) or one RN and a licensed practical nurse (LPN) (depending on agency policy) must check the label on the blood product together against the client's identification number, blood group, and complete name. This minimizes the risk of error in checking information on the blood bag and thereby minimizes the risk of harm or injury to the client. A blood bank technician will verify data with the nurse when the blood is obtained from the blood bank, but will not verify information on the nursing unit or at the client's bedside. The other options are also incorrect.

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? 1. A client scheduled for a chest x-ray. 2. A client requiring daily dressing changes. 3. A postoperative client preparing for discharge. 4. A client receiving oxygen via nasal cannula who had difficulty breathing during the previous shift.

4. Airway is always a highest priority, and the nurse would attend to the client who has been experiencing an airway problem first. The clients described in options 1, 2, and 3 have needs that would be identified as intermediate priorities.

The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. A nursing assistant is resistant to the change and is not taking an active part in facilitating the process of change. Which of the following is the best approach in dealing with the nursing assistant? 1. Ignore the resistance. 2. Exert coercion with the nursing assistant. 3. Provide a positive reward system for the nursing assistant. 4. Confront the nursing assistant to encourage verbalization of feelings regarding the change.

4. Confrontation is an important strategy to meet resistance head on. Face-to-face meetings to confront the issue at hand will allow verbalization of feelings, identification of problems and issues, and development of strategies to solve the problem. Option 1 will not address the problem. Option 2 may produce additional resistance. Option 3 may provide a temporary solution to the resistance but will not address the concern specifically.

The nurse gives an inaccurate dose of a medication to a client. Following assessment of the client, the nurse completes an incident report. The nurse notifies the nursing supervisor of the medication error and calls the physician to report the occurrence. The nurse who administered the inaccurate medication dose understands that: 1. The error will result in suspension. 2. The incident will be reported to the board of nursing. 3. The incident will be documented in the personnel file. 4. An incident report needs to be completed and is a method of promoting quality care and risk management.

4. Documentation of unusual occurrences, incidents, and accidents and of the nursing actions taken as a result of the occurrence is internal to the institution or agency and allows the nurse and administration to review the quality of care and determine any potential risks present. Based on the information provided in the question, the nurse's error will not result in suspension, nor will it be documented in the personnel file. The error and the situation presented in the question are not a reason for notifying the board of nursing.

The registered nurse arrives at work and is told to report (float) to the intensive care unit for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which action first? 1. Call the hospital lawyer. 2. Refuse to float to the ICU. 3. Call the nursing supervisor. 4. Report to the ICU and identify tasks that can be performed safely.

4. Floating is an acceptable legal practice used by hospitals to solve their understaffing problems. Legally, a nurse cannot refuse to float unless a union contract guarantees that nurses can work only in a specified area or the nurse can prove the lack of knowledge for the performance of assigned tasks. When encountering this situation, the nurse should set priorities and identify potential areas of harm to the client. The nursing supervisor is called if the nurse is expected to perform tasks that he or she cannot safely perform. Calling the hospital lawyer is a premature action.

The nurse has made an error in documenting an assessment finding on a client and obtains the client's record to correct the error. The nurse corrects the error by: 1. Documenting a late entry into the client's record. 2. Trying to erase the error for space to write in the correct data. 3. Using white-out to delete the error to write in the correct data. 4. Drawing one line through the error, initialing and dating the line, then documenting the correct information.

4. If the nurse makes an error in documenting in the client's record, the nurse should follow agency policies to correct the error. This includes drawing one line through the error, initialing and dating the line, and then documenting the correct information. A late entry is used to document additional information not remembered at the initial time of documentation. Erasing data from the client's record and the use of Wite-Out are prohibited.

A nurse employed in an emergency department is assigned to triage clients arriving to the emergency room for treatment on the evening shift. The nurse should assign highest priority to which of the following clients? 1. A client complaining of muscle aches, a headache, and malaise. 2. A client who twisted her ankle when she fell while rollerblading. 3. A client with a minor laceration on the index finger sustained when cutting an eggplant. 4. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce.

4. In an emergency department, triage involves brief client assessment to classify clients according to their need for care and includes establishing priorities of care. The type of illness or injury, the severity of the problem, and the resources available govern the process. Clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, acute neurological deficits, and those who have sustained chemical splashes to the eyes are classified as emergent and are the number 1 priority. Clients with conditions such as a simple fracture, asthma without respiratory distress, fever, hypertension, abdominal pain, or a renal stone have urgent needs and are classified as number 2 priority. Clients with conditions such as a minor laceration, sprain, or cold symptoms are classified as nonurgent and are the number 3 priority.

A labor and delivery room nurse has just received report on four clients. The nurse should assess which client first? 1. A primiparous client in the active stage of labor. 2. A multiparous client who was admitted for induction of labor. 3. A client who is not contracting, but has suspected premature rupture of the membranes. 4. A client who has just received an IV loading dose of magnesium sulfate to stop preterm labor.

4. Magnesium sulfate is a central nervous system (CNS) depressant and the client could experience adverse effects that includes depressed respiratory rate (below 12 breaths/min), severe hypotension, and absent deep tendon reflexes (DTRs). This client should be seen before the clients in options 1, 2, and 3 because these clients conditions represent stable ones.

7. As goals, outcomes, and interventions are developed, the nurse must: 1. Be in charge of all care and planning for the client. 2. Be aware of and committed to accepted standards of practice from nursing and other disciples. 3. Not change the plan of care for the client. 4. Be in control of all interventions for the client.

B

6. The nurse writes an expected outcome statement in measurable terms. An example is: 1. Client will have less pain. 2. Client will be pain free. 3. Client will report pain acuity less than 4 on a scale of 0-10. 4. Client will take pain medication every 4 hours around the clock.

C

22. After assessing the client, the nurse formulates the following diagnoses. Place them in order of priority, with the most important (classified as high) listed first. 1. Constipation 2. Anticipated grieving 3. Ineffective airway clearance 4. Ineffective tissue perfusion.

C, D, A, B

3. Priorities are established to help the nurse anticipate and sequence nursing interventions when a client has multiple problems or alterations. Priorities are determined by the client's: 1. Physician 2. Non Emergent, non-life threatening needs 3. Future well-being. 4. Urgency of problems

D

A nurse is monitoring a client receiving parenteral nutrition. The client suddenly develops respiratory distress, dyspnea, and chest pain, and the nurse suspects air embolism. What are the actions that the nurse would take in order of priority. A. Administer oxygen. B. Contact the physician. C. Document the occurrence. D. Take the client's vital signs. E. Clamp the intravenous catheter. F. Position the client in Trendelenburg position.

E, F, B, A, D, C. If air embolism is suspected, the nurse would first clamp the intravenous catheter to prevent the embolism from traveling through the heart to the pulmonary system. The nurse would next place the client in a left side-lying position with the head lower than the feet (to trap air in right side of the heart). The nurse would notify the physician and administer oxygen as prescribed. The nurse would monitor the client closely and take the client's vital signs. Finally, the nurse documents the occurrence.

A client involved in a head-on automobile crash has awakened from a coma and asks for her husband, who was killed in the same accident. The family does not want the client to know at this time that her husband has died. The family wants all nursing staff to tell the client that the husband was taken by helicopter to another hospital, has a head injury, and is in the ICU. Because the American Nurses Association Code of Ethics requires the nurse to preserve integrity, but the nurse wants to follow the family's instruction, the nurse faces an ethical dilemma. Number in order the steps for systematic processing of the ethical dilemma. A.Evaluate the action. B.Verbalize the problem. C.Negotiate the outcome. D.Consider possible courses of action. E.Gather all of the information relevant to the case. F.Examine and determine one's own values on the issues.

E, F, B, D, C, A. Ethical reasoning is the process of thinking through what one ought to do in an orderly and systematic manner to provide justification for actions based on principles. First, the nurse determines whether or not the issue involves an ethical dilemma and gathers information that is relevant to the case. Next, the nurse undertakes personal value clarification and identifies his or her own values regarding the issue. Third, the nurse verbalizes the problem in a simple sentence. Fourth, the nurse considers possible courses of action. In this case, the nurse may choose to seek the counsel of the agency's ethicist regarding the issue. Fifth, the nurse negotiates the outcome by developing a confidence in her or his own point of view with deep respect for the opinions of others. In this case, the nurse may negotiate with the family to determine a course of action that will allow the nurse to preserve integrity and yet allow the family to determine when the client should be informed of the tragic loss. Finally, the nurse evaluates the action.