Chapter 17 Implementing
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? • Time and resources • The client's condition • Finances of the client • Feedback from the family
Correct response: • Finances of the client Explanation: The client's condition, time and resources, and feedback or input from the family are all of great value when the nurse is prioritizing the client's nursing diagnoses. The client's finances, however, should not influence the nurse's priority setting. The nursing code of ethics states that clients should receive the same treatment regardless of their ability to pay.
Which task would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? • Retrieve a unit of blood from the blood bank. • Reassess the client's sacrum for redness when doing a bed bath. • Secure the client's jewelry before surgery. • Provide the client with assistance in transferring to the bedside commode.
Correct response: • Provide the client with assistance in transferring to the bedside commode. Explanation: Assisting with toileting is one of the tasks the state board of nursing permits UAPs to perform. UAPs commonly performed this task in health facilities. Each of the other responses demands a level of responsibility that the nurse cannot legally delegate to a UAP.
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? • Initiate an intravenous line and administer 500mL of normal saline. • DIscuss the need to change positions slowly, especially when moving from sitting to standing. • Perform vital signs and blood glucose level. • Perform a full review of systems.
Correct response: • Perform vital signs and blood glucose level. Explanation: A patient who presents with severe dizziness needs a comprehensive assessment, including vital signs and blood glucose level, prior to any other action. The results of the assessment could help determine which actions to take next. Discussing the need to change positions slowly and home blood pressure monitoring may be appropriate educational activities for this client, but the assessment should be performed first to be sure that the client's symptoms are caused by hypotension. The client may also need intravenous fluids to help correct hypotension, but the client must be assessed first.
Which nursing action can be categorized as a surveillance or monitoring intervention? • Administering a paracetamol tablet • Auscultating of bilateral lung sounds • Use of therapeutic communication skills • Providing hygiene
Correct response: • Auscultating of bilateral lung sounds Explanation: 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 physician 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.
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? • Arrange with the nurse case manager for an early discharge. • Encourage the client to provide as much self-care as possible. • Teach the family to anticipate the client's needs to care for the client. Perform all care activities for the client to facilitate rest.
Correct response: • Encourage the client to provide as much self-care as possible. Explanation: 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.
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? • Interview the family to determine if the client is giving accurate information. • Inform the client that the blood pressure medication will have to be changed. • Reinforce the instructions for the treatment regimen to the client. • Report the findings to the physician for further plans.
Correct response: • Report the findings to the physician for further plans. Explanation: The nurse should report the findings to the physician so that the treatment regimen can be revised. The client reports following the treatment regimen, so reinforcing the instructions is not indicated. Interviewing the family would indicate to the client that the nurse did not trust the client's report, so this would be inappropriate. The nurse cannot tell the client that the blood pressure medication will have to be changed because that is the physician's decision.
While observing a new nurse inserting an indwelling urinary catheter, the preceptor observes a break in sterile technique. What is the preceptor's first action? • Report the new nurse's error to the nurse manager for corrective action. • Tell the new nurse that a break in sterile technique has occurred and the procedure must be stopped. • Assign the new nurse to view videos on sterile catheter insertion. • Allow the new nurse to continue with the insertion and discuss the error later away from the client.
Correct response: • Tell the new nurse that a break in sterile technique has occurred and the procedure must be stopped. Explanation: The most important priority is to ensure the client's safety. Because the new nurse has contaminated the sterile field, the risk of introducing infection is high. The procedure must be discontinued. Because the preceptor is working with the new nurse, it would not be necessary to report the new nurse's error to the nurse manager unless it became a pattern of behavior. Assigning the nurse to watch instructional videos might be appropriate, but after the client care issue is resolved.
A nurse who is experienced caring only for well babies is assigned to the neonatal intensive care unit (NICU) because of a shortage of nurses in the NICU. The nurse is assigned to an infant on a ventilator who will require blood transfusions during the shift. What is the nurse's mostappropriate course of action? • The nurse should recognize the necessity of the assignment and provide care to the best of the nurse's ability. • The nurse should inform the charge nurse that the nurse does not have the experience to properly care for this client. • The nurse should ask another nurse who was previously assigned to the client for instruction. • The nurse should request that the blood transfusions be delayed until the next shift.
Correct response: • The nurse should inform the charge nurse that the nurse does not have the experience to properly care for this client. Explanation: The nurse should recognize that the nurse lacks the competence to safely care for a client with these complex needs and inform the charge nurse of the fact. This assignment would be an inappropriate delegation on the part of the charge nurse and could cause injury to the client. The other options do not take the safety of the client into consideration.
Which statement by a nurse case manager regarding this nurse's role in client care is most accurate? • "Even though I do not provide care to clients, my work is very important." • "Moving away from client care is a necessary step to advancing my career." • "I provide a critical service that is necessary for financial reimbursement." • "I provide indirect care to my clients by coordinating their treatment with other disciplines."
Correct response: • "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.
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." • "I sort my medication into an organizer every week." • "My daughter has been staying with me the past few weeks." • "I asked my neighbors to help me with my yard work."
Correct response: • "My wife's been gone for about 7 months now." Explanation: The client's loss may be affecting how well the client is able to provide self-care. The client may be depressed and questioning the benefits of the health care regimen, or the client may have depended on the wife to help with health care and no longer has the ability to take care of himself. Assessment of the client allows the nurse to alter the plan of care to meet the client's needs. The statements concerning having a family member staying with the client, having help with the yard work, and sorting medications into an organizer all indicate factors that would improve the client's ability to provide self-care, not decrease it.
A client requires a change and reapplication of a colostomy bag. The nurse has never changed an ostomy bag before. What is the nurse's best course of action? • Ask the client how the bag is changed. • Determine the necessity of the bag change. • Read the policy and procedure manual. • Ask a skilled nurse to assist with the procedure.
Correct response: • Ask a skilled nurse to assist with the procedure. Explanation: Professional nurses should only undertake tasks that they have been properly trained to perform. Because the nurse has no experience in changing an ostomy bag, it would be most appropriate to have the assistance of an experienced nurse. It would be inappropriate to ask the client how the bag is changed. The client is relying on the nurse to have the necessary technical knowledge. Reading the policy and procedure manual alone would not ensure the successful completion of the procedure. The necessity of the ostomy bag change has already been established.
A nurse suspects that the client with Crohn's disease does not understand the medication regimen or diet modifications required to manage the illness. What is the nurse's mostappropriate action? • Ask the gastroenterologist to explain the treatment plan to the client and family again. • Ask the client to verbalize the medication regimen and diet modifications required. • Ask the nutritionist to give the client strict meal plans to follow. • Refer the client to available community resources and support groups.
Correct response: • Ask the client to verbalize the medication regimen and diet modifications required. Explanation: If the nurse suspects a client does not understand instructions, the first step is to assess the client's understanding. The most effective way to do that is to have the client repeat the client's understanding of the instructions. The other steps might be interventions that the nurse would institute after determining the client's needs.
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. • Inform the surgeon that the nurse will not sign the informed consent form. • Ask the client whether the client is afraid that the spouse will be angry. • Remind the client that the client is responsible for the client's own health care decisions.
Correct response: • Ask the surgeon to wait until the client has had a chance to talk to the spouse. Explanation: It is important to consider the client's wishes, so the nurse should advocate for the client and ask the surgeon to wait until the client has talked to the spouse. Telling the client that the client is responsible for the client's own health care decisions does not respect the client's desire to consult the spouse. The client has not expressed being fearful of the spouse. Informing the surgeon that the nurse will not sign the consent form will not satisfy the client's request.
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? • Tell the client to report any side effects experienced. • Ask the client to verbalize the purpose of the medication. • Assess the client's blood pressure to determine if the medication is indicated. • Determine the client's reaction to the medication in the past
Correct response: • Assess the client's blood pressure to determine if the medication is indicated. Explanation: Before initiating any intervention, the nurse must determine if the intervention is still necessary. Before administering blood pressure medication, the blood pressure must be assessed. The client's reaction to the medication previously does not indicate if the medication is indicated at this time. The client's ability to verbalize the purpose of the medication is important to promote self-care, but it is not important for the client's safety at this time. The client's report of side effects would indicate an adverse reaction after the medication is administered, but it would not protect the client's safety before the medication is given.
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? • Inform the family that it is not possible to change the discharge plans. • Instruct the client to make alternate living arrangements. • Communicate with the physician about additional orders. • Collaborate with other disciplines to revise the discharge plans.
Correct response: • Collaborate with other disciplines to revise the discharge plans. Explanation: 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 physician 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.
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? • Collaborate with the physical therapist to determine the client's ability. • Assess the client to determine whether the client is capable of ambulation. • Communicate with the physicians to coordinate their orders. • Instruct the client to ask the physicians for clarifications of instructions.
Correct response: • Communicate with the physicians to coordinate their orders. Explanation: 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 physicians 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 physicians' orders have to be clarified first.
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 mostappropriate action? • Instruct the client to refuse the diagnostic tests if the client becomes too fatigued. • Review the physician's progress notes to determine if any of the tests are not indicated. • Coordinate with the other disciplines to determine if all the tests scheduled are necessary. • Coordinate with the other disciplines to schedule the tests with adequate rest for the client.
Correct response: • Coordinate with the other disciplines to schedule the tests with adequate rest for the client. Explanation: The nurse's most appropriate course of action is to coordinate with the other disciplines to plan the scheduling of the tests with opportunities for the client to rest. Since the tests have been ordered by the physician, the other disciplines and the nurse cannot change the orders without the physician doing so. If the nurse feels that any of the tests are unnecessary, the appropriate course of action would be to consult with the ordering physician. While the client has the right to refuse any treatment, it would be more beneficial to the client if steps were taken earlier to prevent the necessity of the client's refusal.
Which is the nurse's priority question to consider prior to delegating a task to an unlicensed assistive personnel (UAP)? • How can I explain the task to the UAP? • How can I supervise the completion of this task? • What is the client's condition? • Does this task fall within the scope of a UAP?
Correct response: • Does this task fall within the scope of a UAP? Explanation: All of these questions are important, but the priority is whether the task falls within the scope of a UAP. If the answer is no, the rest of the questions are not necessary.
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 • Providing medication for agitation • Repositioning to prevent pressure injuries • Changing the dressing to prevent infection
Correct response: • Ensuring that the endotracheal tube is secure Explanation: The ABCs (airway, breathing, and circulation) are always top priority in client care. In this example, ensuring that the client maintains a patent airway will always be top priority. Each of these nursing tasks is important and will need to be accomplished at some point during client care.
Which action should the nurse take to ensure that an unlicensed assistive personnel (UAP) understands the instructions to perform a delegated task? • Inform the UAP of the importance of following each step listed in the procedure manual. • Request that the UAP place the steps of the task in the framework of the nursing process. • Instruct the UAP to repeat the instructions to be sure the nurse has communicated clearly. • Ask another UAP to observe and assist the UAP in performing the task.
Correct response: • Instruct the UAP to repeat the instructions to be sure the nurse has communicated clearly. Explanation: Instruct the UAP to repeat the nurse's instructions to be sure the nurse has communicated them clearly. The UAP must be clear on the difference between nursing tasks and the nursing process, as the nursing process structures care delivered by the registered nurse. Although it is important for the UAP to follow procedure manuals, it is important that the registered nurse is clear on the UAP's understanding of the steps through direct observation or discussions. It is not correct to ask another UAP to observe and assist the UAP in performing the task.
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? • A senior nursing student present for clinical • Licensed practical nurse • Registered nurse • Nursing assistant
Correct response: • Nursing assistant Explanation: The nurse should avoid delegating the dressing change to the nursing assistant. The dressing change would be within the scope of practice of the registered nurse, licensed practical nurse, and the senior nursing student.
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. • Revise the plan to include the inclusion of a support group. • Report the client's inability to learn to the case manager. • Teach the content again utilizing the same method.
Correct response: • Reassess the appropriateness of the method of instruction. Explanation: It is the nurse's responsibility to revise the plan of care if an intervention is not successful. The most appropriate action of the nurse would be to determine if the initial education was the most effective for this client. Simply teaching the content again without reassessing the client's needs would not necessarily be effective. A support group might be helpful, but not until the client's needs are evaluated. The case manager is not responsible for the client's learning.
An indwelling urinary catheter has been ordered for a client experiencing urinary retention after surgery. When the nurse enters the room to place the catheter, the client reports voiding in the bathroom. Which is the nurse's most appropriate action? • Reassess whether the client still needs the urinary catheter. • Inform the client that the catheter will no longer be necessary. • Insert the urinary catheter as ordered to relieve the urinary retention. • Instruct the client that the catheter is essential to check for urinary retention.
Correct response: • Reassess whether the client still needs the urinary catheter. Explanation: Before any intervention is implemented, the nurse should assess whether the intervention is still indicated. In this case, the client's report of voiding makes it all the more essential that the nurse assess whether the client is still retaining urine before inserting the catheter. The nurse should not tell the client the catheter is necessary or unnecessary until after the nurse has completed the assessment and confirmed whether it is necessary.
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? • Consult with the physical therapist to determine the client's ability. • Continue assisting the client to the bathroom to ensure the client's safety. • Revise the care plan to allow the client to ambulate to the bathroom independently. • Instruct the client's family to assist the client to ambulate to the bathroom.
Correct response: • Revise the care plan to allow the client to ambulate to the bathroom independently. Explanation: 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.
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 not to ambulate the client at this time. • Tell the UAP to ask the client whether the client is comfortable with the UAP assisting ambulation. • Tell the UAP that a different UAP should ambulate the client. • Tell the UAP that the RN will assist the UAP with the client's ambulation.
Correct response: • Tell the UAP that the RN will assist the UAP with the client's ambulation. Explanation: The client's safety is always the nurse's primary concern. If the nurse believes that the UAP is unable to safely ambulate the client at this time, the nurse could offer assistance. By assisting the UAP, the nurse ensures the client's safety while still allowing the new UAP to learn. Having a different UAP ambulate the client or instructing the UAP not to ambulate the client does not assist the UAP in learning. Asking the client whether the client feels comfortable having the UAP ambulate the client is inappropriate.