Chapter 17: Implementing

Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?

Bed bath for the newly admitted client who has multiple skin lesions

Which parties are essential for the nurse to include in the implementation of a client's plan of care?

Client, family, and physician

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.

Which statement best explains why continuing data collection is important?

It enables the nurse to revise the care plan appropriately.

A nurse is about to perform pin site care for a patient who has a halo traction device installed. What is the FIRST nursing action that should be taken prior to performing this care? Administer pain medication. Reassess the patient. Prepare the equipment. Explain the procedure to the patient.

Reassess the patient.

The primary purpose of nursing implementation is to:

help the client achieve optimal levels of health.

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?

Nursing assistant who is a nursing student

Nurses use the NIC Taxonomy structure as a resource when planning nursing care for patients. What information is found in this structure? Case studies illustrating a complete set of activities that a nurse performs to carry out nursing interventions Nursing interventions, each with a label, a definition, and a set of activities that a nurse performs to carry it out, with a short list of background readings A complete list of nursing diagnoses, outcomes, and related nursing activities for each nursing intervention A complete list of reimbursable charges for each nursing intervention

Nursing interventions, each with a label, a definition, and a set of activities that a nurse performs to carry it out, with a short list of background readings

A nurse develops a detailed care plan for a 16-year-old patient who is a new single mother of a premature infant. The plan includes collaborative care measures and home health care visits. When presented with the plan, the patient states, "We will be fine on our own. I don't need any more care." What would be the nurse's best response? "You know your personal situation better than I do, so I will respect your wishes." "If you don't accept these services, your baby's health will suffer." "Let's take a look at the plan again and see if we can adjust it to fit your needs." "I'm going to assign your case to a social worker who can explain the services better."

"Let's take a look at the plan again and see if we can adjust it to fit your needs."

A nurse performs nurse-initiated nursing actions when caring for patients in a skilled nursing facility. Which are examples of these types of interventions? Select all that apply. A nurse administers 500 mg of ciprofloxacin to a patient with pneumonia. A nurse consults with a psychiatrist for a patient who abuses pain killers. A nurse checks the skin of bedridden patients for skin breakdown. A nurse orders a kosher meal for an orthodox Jewish patient. A nurse records the I&O of a patient as prescribed by his health care provider. A nurse prepares a patient for minor surgery according to facility protocol.

A nurse checks the skin of bedridden patients for skin breakdown. A nurse orders a kosher meal for an orthodox Jewish patient. A nurse prepares a patient for minor surgery according to facility protocol.

A student nurse is organizing clinical responsibilities for a patient who is diabetic and is being treated for foot ulcers. The patient tells the student, "I need to have my hair washed before I can do anything else today; I'm ashamed of the way I look." The patient's needs include diagnostic testing, dressing changes, meal planning and counseling, and assistance with hygiene. How would the nurse best prioritize this patient's care? Explain to the patient that there is not enough time to wash her hair today because of her busy schedule. Schedule the testing and meal planning first and complete hygiene as time permits. Perform the dressing changes first, schedule the testing and counseling, and complete hygiene last. Arrange to wash the patient's hair first, perform hygiene, and schedule diagnostic testing and counseling.

Arrange to wash the patient's hair first, perform hygiene, and schedule diagnostic testing and counseling.

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

An RN working on a busy hospital unit delegates patient care to UAPs. Which patient care could the nurse most likely delegate to a UAP safely? Select all that apply. Performing the initial patient assessments Making patient beds Giving patients bed baths Administering patient medications Ambulating patients Assisting patients with meals

Making patient beds Giving patients bed baths Ambulating patients Assisting patients with meals

A school nurse notices that a student is losing weight and decides to perform a focused nutritional assessment to rule out an eating disorder. What is the nurse's best action? Perform the focused assessment as this is an independent nurse-initiated intervention. Request an order from Jill's physician since this is a physician-initiated intervention. Request an order from Jill's physician since this is a collaborative intervention. Request an order from the nutritionist since this is a collaborative intervention.

Perform the focused assessment as this is an independent nurse-initiated intervention.

A student nurse is on a clinical rotation at a busy hospital unit. The RN in charge tells the student to change a surgical dressing on a patient while she takes care of other patients. The student has not changed dressings before and does not feel confident performing the procedure. What would be the student's best response? Tell the RN that he or she lacks the technical competencies to change the dressing independently. Assemble the equipment for the procedure and follow the steps in the procedure manual. Ask another student nurse to work collaboratively with him or her to change the dressing. Report the RN to his or her instructor for delegating a task that should not be assigned to student nurses.

Tell the RN that he or she lacks the technical competencies to change the dressing independently.

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.

A new RN is being oriented to a nursing unit that is currently understaffed and is told that the UAPs have been trained to obtain the initial nursing assessment. What is the best response of the new RN? Allow the UAPs to do the admission assessment and report the findings to the RN. Do his or her own admission assessments but don't interfere with the practice if other professional RNs seem comfortable with the practice. Tell the charge nurse that he or she chooses not to delegate the admission assessment until further clarification is received from administration. Contact his or her labor representative to report this practice to the state board of nursing.

Tell the charge nurse that he or she chooses not to delegate the admission assessment until further clarification is received from administration. The nurse should not delegate this nursing admission assessment because only nurses can perform this intervention. The nurse should seek clarification for this policy from the nursing administration.

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 discusses the specifics of what was taught during the session.

A nurse is using the implementation step of the nursing process to provide care for patients in a busy hospital setting. Which nursing actions best represent this step? Select all that apply. The nurse carefully removes the bandages from a burn victim's arm. The nurse assesses a patient to check nutritional status. The nurse formulates a nursing diagnosis for a patient with epilepsy. The nurse turns a patient in bed every 2 hours to prevent pressure injuries. The nurse checks a patient's insurance coverage at the initial interview. The nurse checks for community resources for a patient with dementia.

The nurse carefully removes the bandages from a burn victim's arm. The nurse turns a patient in bed every 2 hours to prevent pressure injuries. The nurse checks for community resources for a patient with dementia.

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:

standing orders.