PrepU Chapter 17: Implementing

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

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?

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

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. -Initial assessment of the mother after the birth of the infant -Assisting the client with personal hygiene needs and ambulation -Assisting and teaching the client to breastfeed the infant -Providing routine discharge instructions related to infant care -Transporting the infant to the mother's room according to hospital policy

-Assisting the client with personal hygiene needs and ambulation -Transporting the infant to the mother's room according to hospital policy Explanation: It is essential when delegating duties that the registered nurse (RN) is aware the nurse's role and what duties can be delegated. The nurse also must be aware of the training and the competence of the UAP. The nurse could appropriately delegate assisting with personal hygiene needs, ambulation, and transporting the infant to the mother's room according to hospital policy. Assessment is the role of the RN and cannot be delegated. Teaching, including breastfeeding education and discharge instructions, is also the role of the RN and cannot be delegated.

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 blind. -The client denies the need for education.

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

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

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.

Which nursing action can be categorized as a surveillance or monitoring intervention?

Auscultating of bilateral lung sounds

A client on the medical-surgical unit is scheduled for several diagnostic tests. The nurse is concerned that the tests will be too tiring for the client. What would be the nurse's most appropriate action?

Coordinate with the other disciplines to schedule the tests with adequate rest for the client.

Which action is a nursing intervention that facilitates lifespan care?

Educate family members about normal growth and development patterns.

The nurse in a burn intensive care unit (BICU) is caring for a 3-year-old child who was burned with scalding hot water. The client has burns covering 75% of the body. The client's condition is critical but stable. At 1000, the nurse reassesses the client and finds that the client is agitated and pulling at the endotracheal tube. Which is the nurse's priority intervention for this client at this time?

Ensuring that the endotracheal tube is secure

Priority setting is based on the information obtained during reassessment and is used to rank nursing diagnoses. Each factor contributes to priority setting except which?

Finances of the client

Which is an independent (nurse-initiated) action?

Helping to allay a client's fears about surgery

The nurse is preparing a client with a bowel obstruction for emergency surgery. Which intervention has the highest priority for this client?

Inform the client what to expect after the surgery.

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.

Before implementing any planned intervention, which action should the nurse take first?

Reassess the client to determine whether the action is needed.

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

Technical skill

The physician has ordered that the client should ambulate 3 times a day. The nurse enters the room to ambulate the client and the client reports pain. What is the nurse's most appropriate action? -Medicate the client and wait to ambulate later. -Ambulate the client and medicate later. -Emphasize to the client the importance of following the treatment plan. -Explain to the client the benefits of ambulation.

-Medicate the client and wait to ambulate later. Explanation: It is most appropriate to manage the client's pain first. The client will be able to ambulate more easily and it is not necessary to cause the client further pain. Ambulating first considers the needs of the nurse, not the client. The client has not indicated misunderstanding of benefits or the importance of ambulation.

The nurse has instructed the client in self-catheterization, but the client is unable to perform a return demonstration. What is the nurse's most appropriate plan of action?

Reassess the appropriateness of the method of instruction.

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 most appropriate course of action?

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

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.

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?

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

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 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.

Which is the nurse's priority question to consider prior to delegating a task to an unlicensed assistive personnel (UAP)?

Does this task fall within the scope of a UAP?

The primary purpose of nursing implementation is to:

help the client achieve optimal levels of health.

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

standing orders. Explanation: Standing orders empower the nurse to initiate actions that ordinarily require the order or supervision of a physician, such as pain medication administration based on specific criteria. Protocols are written plans that detail the nursing activities to be executed in specific situations; these include routine nursing care and standing orders. Nursing interventions refer to care administered by the nurse and can be dependent or independent in nature. Collaborative orders may include suggested care strategies from other health care personnel such as the physical therapist.standing orders.

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?

Surveillance

The registered nurse is working with an unlicensed assistive personnel. Which client should the nurse not delegate to the unlicensed assistive personnel?

The client with continuous pulse oximetry who requires pharyngeal suctioning.

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.

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?

Collaborate with other disciplines to determine the best way to meet the client's medication requirements.

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 physician of the client's refusal.

Discuss with the client the reasons for declining surgery. Explanation: 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 physician until the assessment is complete.

During morning report, the night nurse tells the oncoming nurse that the client has been medicated for pain and is resting comfortably. Thirty minutes later, the client calls and requests pain medication. What is the nurse's appropriate first action?

Go to the client and assess the client's pain.

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. -Collaborate with other health care professionals about the client's treatment. -Change the nursing care plan.

Identify what barriers the client feels are preventing adherence with the plan. Explanation: 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 physician has ordered that the client should ambulate 3 times a day. The nurse enters the room to ambulate the client and the client reports pain. What is the nurse's most appropriate action?

Medicate the client and wait to ambulate later.

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." Explanation: 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 cannot afford the treatment prescribed. Who would be the most appropriate professional for the nurse to involve with the client's care?

Nurse case manager

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." Explanation: 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.

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 is able to answer the nurse's questions. -The client verbalizes understanding of the instructions. -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 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. Explanation: When reassessing the client after implementing interventions to increase oxygenation, the nurse would look for a decrease in respiratory rate to a more normal rate and an increase in the oxygen saturation level. The client's subjective statement of breathing easier would also indicate effectiveness. The client watching television and the client's family's statement do not indicate anything about oxygenation status.

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 Explanation: 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 physician initiated. The care team cannot independently change a client's advance directive.

Which parties are essential for the nurse to include in the implementation of a client's plan of care? -Client, family, and physician -Client, physician, and hospital director -Client, physical therapist, and nursing staff -Client, surgeon, and physician

Client, family, and physician Explanation: To ensure the success of the care plan, the nurse must involve all necessary parties. It is essential that the client be involved in the client's own health care decisions. The client's family provides needed support, and the physician is essential to provide medical interventions. The hospital director is not necessary for the implementation of the plan of care. A physical therapist and a surgeon are not necessarily involved in every client's care.

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 physician for additional orders. -Determine the client's code status in case of an emergency.

Communicate with the physician for additional orders. Explanation: If the nurse's interventions have been ineffective, the physician must be notified of the client's deteriorating status. The physician 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.

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?

Coordinating

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 possible alternatives to a blood transfusion with the physician.

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. -Collaborate with other health care professionals about the client's treatment. -Change the nursing care plan.

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

Nursing assistant

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 physician to order IM injections with the new technique. -Research the protocols at other area emergency rooms.

Petition to change the protocol based on the new evidence. Explanation: 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 physician 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.

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

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 Explanation: 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.

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?

Reassess the client to determine the effectiveness of the interventions.

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. Explanation: 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.

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?

Standing orders

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 Explanation: 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.

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.

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

The nurse is operating under standing orders for clients with suspected MIs. Explanation: For the nurse to administer medications or order laboratory tests, the nurse must have a physician's order. In special circumstances, such as in the emergency room, there are standing orders in place to authorize the nurse's actions in certain situations. The other three statements may also be true, but they do not give the nurse the authority to institute these actions independent of a physician's order.

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. Explanation: 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. The 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.