N2- Ch. 18 Implementing

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? 1. The nurse encourages clients to advocate for themselves instead of choosing a trusted family member or friend. 2. The nurse encourages the client to participate in all treatment decisions as the center of the health care team.

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

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 needs further information before deciding what interventions are necessary, so the most appropriate action is to determine the client's reasons for refusal. Until the information is collected, the nurse cannot decide whether reviewing the risks and benefits of surgery would be effective. It is also premature to ask the client to discuss the decision with family members. It is not appropriate to notify the health care provider until the assessment is complete.

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

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 case manager is the expert on resources available for the client's care. The nurse manager is responsible for the operation of the nursing unit. The health care provider is concerned with the client's medical needs. The insurance company is a possible resource, if the client has insurance coverage.

The emergency room nurse is performing an initial assessment of a new client who presents with severe dizziness. The client reports a medical history of hypertension, gout, and migraine headaches. Which step should the nurse take first in the comprehensive assessment? Perform vital signs and blood glucose level. Discuss the need to change positions slowly, especially when moving from sitting to standing. Perform a full review of systems. Initiate an intravenous line and administer 500mL of norm

Perform vital signs and blood glucose level.

Before implementing any planned intervention, which action should the nurse take first? Have the required equipment ready for use. Reassess the client to determine whether the action is needed. Ask the client whether this is a good time to do the intervention. Record the planned intervention in the client's medical record.

Reassess the client to determine whether the action is needed. Although being prepared with the necessary equipment and checking with the client to make sure that the client is physically and psychologically ready for the intervention are important, it is crucial to reassess the client to determine whether the action is still needed before implementing any nursing intervention. Recording the intervention occurs after the nurse has completed the intervention.

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 th

Revise the care plan to allow the client to ambulate to the bathroom independently. 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 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 An important nursing function is to enable clients to prevent illness. Because a member of the family has developed diabetes, the other family members are also at risk. The nurse would most appropriately educate the family about the risk factors for and prevention of diabetes mellitus. Knowledge of the medications used to treat diabetes is not necessary at this time and does not help meet the family's needs. The severity of the client's disease does not have an impact on the family's health. Knowledge of the cellular metabolism of glucose is not necessary for the family's health.

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. The nurse needs to perform the pharyngeal suctioning of the client with continuous pulse oximetry. This client requires the nurse to evaluate the client's response in pulse oximetry to the suctioning. The nurse can delegate the other clients to the unlicensed assistive personnel.

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. A key component of the organizing interventions is to ensure adequate equipment (extra supplies) and sufficient personnel to assist with more complex tasks. Skills are first learned in nursing school but then validated with policies and procedures of the institution. Assistance is necessary to assist with the skill but is not the main issue in this scenario. Environment would be related to the lighting and space. Client issues would be the correct response if the client was cognitively aware and not confused. Logistics and planning may be related to other issues such as making sure all the elements such as personnel, client, environment, and assistance are all present.

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? egistered 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

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.

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 health care provider 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. 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 health care provider 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 client tells the nurse, "My doctor has told me I have to have a blood transfusion, but I am a Jehovah's Witness and I can't take one." What is the nurse's most appropriate intervention? Discuss the risks and benefits of a blood transfusion with the client. Discuss possible alternatives to a blood transfusion with the health care provider. Discuss the client's options with other church members. Discuss the client's refusal with hospital risk managers.

Discuss possible alternatives to a blood transfusion with the health care provider. As coordinator of the client's care, the nurse functions as an intermediary between the health care provider and the client. In order to honor the client's wishes, the nurse would most appropriately consult with the health care provider to meet the client's physical needs, as well as the client's spiritual needs. The risk and benefits of a blood transfusion are not the relevant issue with the client. Discussing the client's options with other church members would violate the client's privacy and would not meet the client's physical needs. It might be advisable to discuss the client's refusal of care with the hospital risk manager to protect the legal requirements of the institution, but it is not the priority.

Which action is a nursing intervention that facilitates lifespan care? Educate family members about normal growth and development patterns. Explore factors that could motivate adolescent members of the family to engage in risky behaviors. Identify coping strategies for the family that have worked in the past. Teach contraceptive options for planned pregnancy.

Educate family members about normal growth and development patterns. Knowledge of normal growth and development is essential for family members to promote their own health and welfare throughout the lifespan, and to facilitate family functioning. Childbearing care includes interventions to assist in understanding and coping with psychological and physiologic changes during the childbearing period. Coping assistance includes interventions to assist the client in building on his or her strengths, to adapt to a change in function, or to achieve a higher level of function. Risk management includes interventions to initiate risk reduction activities.

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. Continuous data collection ensures that the nurse has the most current client data to evaluate, which allows for updating the care plan as needed. A complete assessment is performed on admission, but the client's condition is always changing. The purpose of continued data collection is to provide good client care; it does not relate directly to efficiency of nursing care. While continuous data collection meets standards of care, it is not the primary reason for ongoing assessments.

The nurse is caring for a client who does not speak the same language. The (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. Orient the client and family to the room, including the call light button. Ask the client questions regarding personal care needs.

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

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 health care provider orders, the nurse administers naloxone. Which would allow the nurse to initiate this action? Algorithm Standing orders Protocol Order set

Standing orders Standing orders allow the nurse to initiate actions that ordinarily require the order of a health care provider, 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.

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.

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. The nurse will include family members or other caregivers in the education to ensure the client has adequate support upon discharge. It would not be appropriate to delegate client teaching to an unlicensed assistive personnel. The nurse should assess the client's learning needs, determine the client's preference, and provide the appropriate teaching method to promote effective teach-back of the skill; providing only a video may not suffice. Although client education must be documented prior to discharge, the nurse must first provide the education.

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

Administering a glycerin suppository to a constipated client who has not responded to oral stool softeners Standing orders and protocols often surround the management of bowel elimination. Modification of a client's IV fluid or administration of a new antihypertensive are client-specific interventions that are health care provider initiated. The care team cannot independently change a client's advance directive.

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

Assess the client to determine the cause of the pain. One hour after administering pain medication, the nurse would expect the client to be relieved of pain. A new report of intense pain might signal a complication and requires a thorough assessment. The nurse might request an order for additional pain medication, but only after a thorough assessment. Telling the client how often medication can be received does not help relieve the client's pain. Repositioning and splinting the incision are interventions that the nurse might perform, but only after determining the cause of the pain.

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 Surveillance or monitoring nursing interventions include detecting changes from baseline data and recognizing abnormal responses. Nurses rely on the senses to detect changes: observing the appearance and characteristics of clients; hearing by auscultation, pitch, and tone; detecting odors and comparing them with past experience and knowledge of specific problems; and using touch to assess body temperature, skin condition, clamminess, or diaphoresis. Nurses use all of these surveillance or monitoring activities to determine the current status of clients and changes from previous states. Nurses often detect subtle changes in a client's condition and communicate them to the health care provider to minimize problems. Providing hygiene and administering a paracetamol tablet are examples of maintenance nursing interventions. Use of therapeutic communication skills is an example of a supportive nursing intervention.

Discharge plans for a client with a mental health disorder include living with family members. The nurse learns that the family is no longer willing to allow the client to live with them. What is the nurse's most appropriate action? Collaborate with other disciplines to revise the discharge plans. Instruct the client to make alternate living arrangements. Communicate with the health care provider about additional orders. Inform the family that it is not possible to change the discharge plans.

Collaborate with other disciplines to revise the discharge plans. The discharge needs of this client are complicated, and the nurse will need the assistance of other disciplines to make a successful discharge plan. The client should have input into the future living arrangements, but the client does not have the resources to make the arrangements alone. The health care provider may be involved in the discharge plan, but additional orders are not necessary. It is not true (and would be inappropriate) to tell the family that discharge plans cannot be changed. If the family is unwilling to take the client, the placement will be unsuccessful.

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

Communicate with the health care provider for additional orders. If the nurse's interventions have been ineffective, the health care provider must be notified of the client's deteriorating status. The health care provider can direct other medical interventions. Documenting the interventions does not take priority over the client's physiologic needs. Allowing another 30 minutes to elapse before taking action will only cause further deterioration in the client's status. The nurse should know the client's code status when taking over the client's care.

The nurse is caring for a client who is recovering from a cerebrovascular accident. When reviewing the orders, the nurse notes that one of the health care providers wrote orders to ambulate the client, whereas another health care provider ordered strict bed rest for the client. How would the nurse most appropriately remedy this conflict? Assess the client to determine whether the client is capable of ambulation. Communicate with the health care providers to coordinate their orders. Collaborate

Communicate with the health care providers to coordinate their orders. As coordinator of care, the nurse is responsible for ensuring the continuity of the treatment plan. If conflicts occur in the treatment plan, the nurse should first consult with the health care providers who have written the conflicting orders. The nurse may assess the client to determine whether the client is capable of ambulation, but this does not resolve the conflict or determine whether ambulation is in the client's best interest. It is not the client's responsibility to clarify nursing orders. Collaboration with the physical therapist could become part of the plan later, but the health care providers's orders have to be clarified first.

The client is in a rehabilitation unit after a traumatic brain injury. In order to facilitate the client's recovery, what would be the nurse's most appropriate intervention? Encourage the client to provide as much self-care as possible. Perform all care activities for the client to facilitate rest. Teach the family to anticipate the client's needs to care for the client. Arrange with the nurse case manager for an early discharge.

Encourage the client to provide as much self-care as possible. The nurse must encourage the client to provide as much self-care as possible in order to achieve the highest level of independence. Performing all care activities for the client makes the client dependent on the nurse. If the family anticipates and meets all the client's needs, this also hinders the client's recovery. An early discharge is not indicated because the client must be sufficiently recovered.

Which is an independent (nurse-initiated) action? Executing health care provider orders for a catheter Meeting with other health care professionals to discuss a client Helping to allay a client's fears about surgery Administering medication to a client

Helping to allay a client's fears about surgery An independent (nurse-initiated) action is one that a nurse may initiate and carry out independently, without an order from any other health care provider. Helping the client decrease fear about surgery by answering questions or arranging a meeting with the surgeon is an independent nursing intervention. Interventions that involve executing a health care provider's orders, such as for catheterization and medication administration, are dependent nursing interventions. Meeting with other health care professionals describes collaborative care.

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 restaurant 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. Collabora

Identify what barriers the client feels are preventing adherence with the plan. The nurse must first identify why the client is not following the therapy before collaboration with other health care professionals or a change in the nursing care plan can be initiated. Simply explaining the effects of a high-salt diet and smoking on the blood pressure may not address the underlying cause of why the client is choosing not to follow the recommended care.

The emergency room (ER) has a strict protocol regarding intramuscular (IM) injection technique. A nurse working in the ER has learned of a new technique to decrease pain with IM injections from the nursing literature and would like to use it. What is the most appropriate way for the nurse to implement the technique? Begin using the technique to determine whether it is effective. Petition to change the protocol based on the new evidence. Ask the ER health care provider to order IM injections wit

Petition to change the protocol based on the new evidence. The nurse should petition to change the protocol on the basis of the new evidence. If the nurse believes that the change would be beneficial to clients, it is important to change the procedure for all clients. Therefore, having the ER health care provider write orders would not be the best choice because it would not affect all clients. Because the nurse must function under the protocols of the agency, it would be wrong to begin using the technique before the protocol is changed. Protocols at other area emergency rooms are not as authoritative as evidence from the nursing literature.

Which nursing actions reflect the implementing step of the nursing process? Select all that apply. Selecting culturally sensitive nursing interventions 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

Providing health education to reduce health risks Referring the client to community resources, when necessary Using evidence-based interventions individualized for the client Examples of the implementing step include using evidence-based interventions individualized for the client; providing health education to reduce health risks; and referring the client to community resources, when necessary. Selection of nursing interventions occurs in the planning step. Determining the client's response to nursing interventions occurs in the evaluating step.

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 Surveillance or monitoring nursing interventions include detecting changes from baseline data and recognizing abnormal responses. Nurses rely on the senses to detect changes, such as observing the appearance and characteristics of clients and hearing by auscultation, pitch, and tone. Nurses use these surveillance activities to determine the current status of clients and changes from previous states. Maintenance nursing interventions involve the nurse assisting the client with performing routine activities of daily living. Supportive nursing measures involve providing basic comfort and emotional care to the client. Collaborative nursing interventions involve coordination and communication with health care professionals in other fields to meet the client's needs.

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 interventions include detecting changes from baseline data and recognizing abnormal response. Nurses rely on the senses to detect changes, such as observing the appearance and characteristics of clients and hearing by auscultation, pitch, and tone. Nurses use these surveillance activities to determine the current status of clients and changes from previous states. Educational interventions require instruction, demonstration, and return demonstration of knowledge or a skill set. Psychomotor interventions involve the nurse physically working with the client. Maintenance interventions involve the nurse assisting the client with performing routine activities of daily living.

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 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. If the family has experience caring for a child with a seizure disorder, the family would already have some basic knowledge, so the nurse would address the education differently. The client expressing a desire to learn indicates receptiveness to the education. The parents' acceptance of their child's condition indicates that they are ready to begin dealing with the child's condition. The fact that the child has comprehensive insurance coverage is a strength that will make options available to the family, but will not necessarily change the nurse's educational plan.

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.