Chap. 17: Implementing- PrepU

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

Auscultating of bilateral lung sounds

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

The nurse is caring for a vegetarian who has iron deficiency anemia. The standardized nutritional plan for a client with anemia calls for the client to increase consumption of animal protein. How should the nurse plan to meet this client's nutritional needs?

Collaborate with the nutritionist to modify the nutritional plan.

The nurse is caring for a client who is recovering from a cerebrovascular accident. When reviewing the client's orders, the nurse notes that one of the physicians wrote orders to ambulate the client, whereas another physician ordered strict bed rest for the client. How would the nurse most appropriately remedy this conflict?

Communicate with the physicians to coordinate their orders.

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?

Discontinue the education and attempt at another time.

Which is an independent (nurse-initiated) action?

Helping to allay a client's fears about surgery

The nurse caring for a client who is recovering after a motor vehicle accident is planning for the client to begin increasing responsibility for self-care. Which would be the nurse's most appropriate strategy?

The nurse encourages the client to take a shower instead of receiving a bed bath.

A client is admitted to the mental health center after attempting suicide. Which client concern is the priority for the nurse to manage?

risk of self-harm

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.

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 responsibility of the nurse in the nurse-nurse team relationship?

Provide creative leadership to make the nursing unit a challenging place to work.

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

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.

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.

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 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.

A nurse is caring for a client with burns. Place the steps in the appropriate order for providing wound care for the client. Use all options.

1. Remove old dressing. 2. Assess condition of wound. 3. Obtain a culture. 4. Open sterile dressing tray. 5. Change from clean to sterile gloves. 6. Record color and odor of discharge

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.

The nurse is caring for a client with congestive heart failure. The nurse manager informs the nurse that the client was enrolled in a clinical trial to assess whether a 10-minute walk, 3 times per day, leads to expedited discharge. Which type of evaluation best describes what the researchers are examining?

Outcome

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?

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

A client with hypertension being seen for follow-up care has a blood pressure of 160/100 mm Hg. The client reports following the treatment regimen closely and that blood pressure readings have been elevated for the last 2 weeks. What is the nurse's most appropriate action?

Report the findings to the physician for further plans.