Chapter 17: Implementing - ML4
Which examples of nursing actions involve direct care of the client? Select all that apply. 1. A nurse massages the back of a client while performing a skin assessment. 2. A nurse arranges for a consultation for a client who has no health insurance. 3. A nurse counsels a young family who is interested in natural family planning. 4. A nurse arranges for physical therapy for a client who had a stroke. 5. A nurse helps a client in hospice fill out a living will form.
1, 3, 5 A direct care intervention is a treatment performed through interaction with the client(s). Direct care interventions include both physiologic and psychosocial nursing actions, and include both the "laying of hands" actions and those that are more supportive and counseling in nature. An indirect care intervention is a treatment performed away from the client but on behalf of a client or group of clients. Indirect care interventions include nursing actions aimed at management of the client care environment and interdisciplinary collaboration. Reference: Chapter 17: Implementing - Page 418
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 parents have comprehensive insurance coverage for their family's medical care. The parents verbalize acceptance of the need to closely monitor their child's condition. 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 client has a 12-year-old sister who has been treated for a seizure disorder for 3 years. Explanation: 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. Reference: Chapter 17: Implementing - Page 416
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? An older adult with pneumonia who is being discharged to the son's home tomorrow An adult client who is being treated for kidney stones A client with a high fever receiving intravenous fluids, antibiotics, and oxygen A middle-aged client who had abdominal surgery 3 days ago and is ambulating in the hall
A client with a high fever receiving intravenous fluids, antibiotics, and oxygen Explanation: For delegation, the circumstances must be right. The health condition of the client must be stable. The client with a high fever receiving intravenous fluids, antibiotics, and oxygen is the least stable of the clients listed and should be assessed by the nurse. Delegation of taking vital signs would be appropriate for all of the other client's described. Reference: Chapter 17: Implementing - Page 428-429
The nurse is caring for a client admitted to the hospital for renal calculi. What is the action to take first? Strain urine after each void. Diet as tolerated. Assess for bladder distention. Force fluids by mouth.
Assess for bladder distention. Explanation: Urinary retention could occur if a kidney stone has become lodged in the urethra. Forcing fluids, straining the urine after each void, and diet as tolerated are appropriate interventions, but these do not address the safety issue of first assessing the bladder for distension, which could potentially cause the client discomfort and harm. Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 14: Implementing, pp. 303, 311-312.
Which action is a nursing intervention that facilitates lifespan care? Explore factors that could motivate adolescent members of the family to engage in risky behaviors. Teach contraceptive options for planned pregnancy. Educate family members about normal growth and development patterns. Identify coping strategies for the family that have worked in the past.
Educate family members about normal growth and development patterns. Explanation: 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. Reference: Chapter 17: Implementing - Page 414
Before implementing any planned intervention, which action should the nurse take first? Have the required equipment ready for use. 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.
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. Reference: Chapter 17: Implementing - Page 419
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 Maintenance Educational Psychomotor
Surveillance Explanation: 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. Reference: Chapter 17: Implementing - Page 423
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? The nurse assures the client who questions a medication that it is the right medication prescribed for him or her and administers the medicine. The nurse encourages clients to advocate for themselves instead of choosing a trusted family member or friend. The nurse encourages the client to participate in all treatment decisions as the center of the health care team. The nurse explains each procedure twice to prevent client questions from wasting time.
The nurse encourages the client to participate in all treatment decisions as the center of the health care team. Explanation: TJC encourages clients to become active, involved, and informed participants on the health care team. By becoming involved and "speaking up" research shows that clients who take part in decisions about their health care are more likely to have better outcomes. The nurse should never want to prevent client questions. While clients are encouraged to be independent, trusted family members and friends can be an asset to the client's care. The nurse should investigate the possibility of an error if the client questions the nurse about a medication. Reference: Chapter 17: Implementing - Page 423-424
Which statement by a nurse case manager regarding this nurse's role in client care is most accurate? "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." "I provide a critical service that is necessary for financial reimbursement." "Even though I do not provide care to clients, my work is very important."
"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. Reference: Chapter 17: Implementing - Page 418
The nurse is assessing a client with a diagnosis of hypertension. The client's blood pressure is 178/88 mm Hg, an increase from 134/78 mm Hg at the previous clinic visit. The nurse asks the client what has changed from the previous visit. Which client statement identifies a potential factor interfering with the plan of care? "We moved to a new neighborhood that has several walking trails, but they are all uphill and really difficult." "My son gave me a blood pressure machine to monitor my blood pressure at home, and I use it every day." "My grandchildren have moved in with us while their parents are going through financial difficulties." "I am taking a cooking class at the community college to learn new healthy cooking techniques."
"My grandchildren have moved in with us while their parents are going through financial difficulties." Explanation: Many physical, emotional, social, and environmental factors can affect the client's health status and self-care behaviors. In this case, having the grandchildren move in due to financial hardships can be stressful, which would raise the client's blood pressure. Having new healthy cooking techniques, walking more (even if it is uphill and difficult), and home monitoring of blood pressure are all health-promoting activities, which should help to lower blood pressure. Reference: Chapter 17: Implementing - Page 428
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. 1. The client is married. 2. The client is male. 3. The client denies the need for education. 4. The client is blind. 5. The client is an architect.
4, 3. Explanation: The client's blindness will require the nurse to alter the education plan to fit the client's needs. The education might also require teaching another person to perform the wound care. If the client denies the need for education, attempting to teach the client at this time will be ineffective. The nurse will need to determine why the client denies the need for teaching and address that issue first. The facts that the client is male, married, and an architect do not have any bearing on the instruction. Reference: Chapter 17: Implementing - Page 417-425
Which are appropriate guidelines for the nurse to follow when delegating tasks to an unlicensed assistive personnel (UAP)? Select all that apply. 1. Delegate tasks that are within the UAP's scope of practice. 2. Provide feedback to the UAP after the task is completed. 3. Provide appropriate supervision when delegating tasks. 4. Delegate correctly to avoid the UAP asking questions about the task. 5. Delegate tasks that involve minimal risk.
All except 4 Explanation: Delegation is the transfer of responsibility for the performance of a task to another staff member while retaining accountability for the outcome. A licensed registered nurse (RN) may delegate tasks to a UAP. When delegating tasks, the RN must ensure that the task is within the UAP's scope of practice. This is considered "Right Person." Delegated tasks should involve minimal risk. This is considered "Right Task." The RN should provide appropriate supervision when delegating tasks ("Right Circumstance") as well as provide feedback after the task is completed ("Right Evaluation"). "Right Communication" involves identifying tasks and expectations for client assignment, providing clear report, including unique client requirements and expected observations to report and record, and assessing the UAP's understanding of expectations, welcoming questions and providing clarification if needed. Thus, avoiding the UAP asking questions is unprofessional and potentially dangerous to the client. Reference: Chapter 17: Implementing - Page 429
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? Determine the necessity of the bag change. Ask the client how the bag is changed. Ask a skilled nurse to assist with the procedure. Read the policy and procedure manual.
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. Reference: Chapter 17: Implementing - Page 428-429
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 most appropriate action? Ask the client to verbalize the medication regimen and diet modifications required. Ask the gastroenterologist to explain the treatment plan to the client and family again. Refer the client to available community resources and support groups. Ask the nutritionist to give the client strict meal plans to follow.
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. Reference: Chapter 17: Implementing - Page 428
One hour after receiving pain medication, a postoperative client reports intense pain. What is the nurse's appropriate first action? Discuss the frequency of pain medication administration with the client. Assess the client to determine the cause of the pain. Assist the client to reposition and splint the incision. Consult with the physician for additional pain medication.
Assess the client to determine the cause of the pain. Explanation: 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. Reference: Chapter 17: Implementing - Page 417
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. Assess the client's blood pressure to determine if the medication is indicated. Ask the client to verbalize the purpose of the medication. Determine the client's reaction to the medication in the past.
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. Reference: Chapter 17: Implementing - Page 419-425
The nurse has assisted the client to ambulate for the first time. After returning the client to bed, what is the nurse's priority intervention? Assess the client's response to the ambulation. Inform the client when ambulation is scheduled next. Document the client's ambulation. Discuss the client's feelings about the illness.
Assess the client's response to the ambulation. Explanation: After a nurse has performed an intervention, the next step is to evaluate the effectiveness of the intervention. The nurse should assess the client's response to the ambulation. Informing the client when ambulation is scheduled next, discussing the client's feelings, and documenting the ambulation are important, but not until after the client has been reassessed. Reference: Chapter 17: Implementing - Page 425
Which nursing action can be categorized as a surveillance or monitoring intervention? Use of therapeutic communication skills Providing hygiene Administering a paracetamol tablet Auscultating of bilateral lung sounds
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. Reference: Chapter 17: Implementing - Page 417-428
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? Arrange for animal protein to be disguised in the client's meal. Instruct the client that consumption of animal protein is necessary to cure the anemia. Meet with the client's family to emphasize the importance of nutritional modification. Collaborate with the nutritionist to modify the nutritional plan.
Collaborate with the nutritionist to modify the nutritional plan. Explanation: A vegetarian does not consume animal proteins. Although animal proteins are an important source of iron, plant proteins are available. To honor the preferences of the client, the nurse would collaborate with the nutritionist to include these plant sources of protein in the client's diet (instead of the animal protein). It is not true that the client has to consume animal protein to cure the anemia. Meeting with the client's family would be inappropriate because this would violate the wishes of the client. Arranging for animal protein to be disguised in the client's meal would violate the client's trust and would also not be effective in the long term after the client has been discharged. Reference: Chapter 17: Implementing - Page 431
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. Determine the client's code status in case of an emergency. Communicate with the physician for additional orders.
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. Reference: Chapter 17: Implementing - Page 416-418
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? Instruct the client to ask the physicians for clarifications of instructions. Communicate with the physicians to coordinate their orders. 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. 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. Reference: Chapter 17: Implementing - Page 416
The mother of a pediatric client being discharged confides to the nurse that her husband is abusive and she is afraid to return home. What is the nurse's most appropriate action? Advise the mother that she should report her concerns to the police. Coordinate with the case manager to make a safe discharge plan. Give the mother telephone numbers of women's shelters. Arrange for a counseling session for the parents of the client.
Coordinate with the case manager to make a safe discharge plan. Explanation: The nurse's top priority is the safety of the client. The person most qualified to consider the options available to protect the mother and client is the case manager. It is not sufficient to simply give the mother telephone numbers of women's shelters. This does not take into account the possible needs of the child after discharge. Advising the mother that she should report concerns to the police does not address the discharge needs of the client. Arranging a counseling session does not meet the immediate discharge needs of the client. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 14: Implementing, p. 307. Chapter 17: Implementing - Page 307
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? Review the physician's progress notes to determine if any of the tests are not indicated. Coordinate with the other disciplines to schedule the tests with adequate rest for the client. Instruct the client to refuse the diagnostic tests if the client becomes too fatigued. 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. 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. Reference: Chapter 17: Implementing - Page 416
A client cannot afford the treatment prescribed. Who would be the most appropriate professional for the nurse to involve with the client's care? Physician Insurance company Nurse case manager Nurse manager
Nurse case manager Explanation: 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 physician is concerned with the client's medical needs. The insurance company is a possible resource, if the client has insurance coverage. Reference: Chapter 17: Implementing - Page 417-426
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? 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. Give the visitors instructions to leave in 10 minutes.
Delay the instruction until the visitors leave. Explanation: The nurse must take into consideration the client's developmental level and willingness to participate in care in order to successfully implement the plan of care. The client is a teenager and socialization with a peer group is essential, so the nurse would most appropriately wait until the visitors leave. Telling the visitors to leave in 10 minutes might upset the client and hinder the education. Simply asking if the client has questions does not appropriately educate the client. Leaving written information does not ensure that the client will read or understand the information. Reference: Chapter 17: Implementing - Page 419
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. Discuss the risks and benefits of a blood transfusion with the client. Discuss the client's refusal with hospital risk managers. Discuss the client's options with other church members.
Discuss possible alternatives to a blood transfusion with the physician. Explanation: As coordinator of the client's care, the nurse functions as an intermediary between the physician and the client. In order to honor the client's wishes, the nurse would most appropriately consult with the physician 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. Reference: Chapter 17: Implementing - Page 416
The nurse has administered pain medication to a client with a fractured femur. One hour later, the client reports relief of pain. What parameters would the nurse document to support evaluation of pain management? Effectiveness of intervention including current pain scale, time frame, and client self-report. Ability of pain medication to be decreased over a designated period of time along with the time frame to be medication free. What techniques have been used to reduce pain outside of pharmacologic modalities as well as how often they are being practiced. Length of time between requests for pain medication along with pain scale rating and the amount of medication provided.
Effectiveness of intervention including current pain scale, time frame, and client self-report. Explanation: Because the client has reported the effectiveness of the intervention, the next step in implementation is to correctly complete the documentation including client's self-reporting of current pain descriptives, pain scale rating, and how effective interventions have been. Pain medication has not been decreased so this would not support interventions. Likewise, the client has experienced relief so documenting length of time between requests is not what is required at this time. Alternative pain management modalities are not the focus so this would not be appropriate. Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 14: Implementing, p. 307. Chapter 17: Implementing - Page 307
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.
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. Reference: Chapter 17: Implementing - Page 416-419
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? Providing medication for agitation Repositioning to prevent pressure injuries Ensuring that the endotracheal tube is secure Changing the dressing to prevent infection
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. Reference: Chapter 17: Implementing - Page 427-430
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? Determine the frequency of pain medication. Instruct the client in nonpharmacologic pain management. Go to the client and assess the client's pain. Medicate the client with the ordered pain medication.
Go to the client and assess the client's pain. Explanation: The nurse's first action should always be to determine the cause of the client's pain in order to determine the correct intervention. After determining the cause, the nurse can plan how to proceed. The other steps would be appropriate, but only after the assessment. Reference: Chapter 17: Implementing - Page 419
Which is an independent (nurse-initiated) action? Executing physician orders for a catheter Administering medication to a client Meeting with other health care professionals to discuss a client Helping to allay a client's fears about surgery
Helping to allay a client's fears about surgery Explanation: An independent (nurse-initiated) action is one that a nurse may initiate and carry out independently, without an order from a physician or 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 physician's orders, such as for catheterization and medication administration, are dependent nursing interventions. Meeting with other health care professionals describes collaborative care. Reference: Chapter 17: Implementing - Page 424-433
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? Identify what barriers the client feels are preventing adherence with the plan. Change the nursing care plan. Collaborate with other health care professionals about the client's treatment. 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. 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. Reference: Chapter 17: Implementing - Page 428
The nurse is preparing a client with a bowel obstruction for emergency surgery. Which intervention has the highest priority for this client? Instruct the client and family in wound care. Discuss discharge plans with the client. Teach the client about dietary restrictions during recovery. Inform the client what to expect after the surgery.
Inform the client what to expect after the surgery. Explanation: If the surgery is an emergency, the highest priority is to meet the client's immediate needs. The nurse should inform the client about what to expect after surgery. Discussing discharge plans, instructing in wound care, and teaching about dietary restrictions are important, but not necessary before the surgery. Reference: Chapter 17: Implementing - Page 424
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 Nursing assistant Licensed practical nurse Registered nurse
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. Reference: Chapter 17: Implementing - Page 429
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? Registered nurse A senior nursing student present for clinical Nursing assistant who is a nursing student Licensed practical nurse
Nursing assistant who is a nursing student Explanation: The nurse should avoid delegating this client to the nursing assistant who is a nursing student. Suctioning and the associated evaluation of the client would be within the scope of practice of the registered nurse, licensed practical nurse, and the senior nursing student present for clinical. Reference: Chapter 17: Implementing - Page 429
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? Structure Outcome Process Cost-effectiveness
Outcome Explanation: Outcome evaluation focuses on measurable changes in the health status of the client or the end results of nursing care, such as an expedited discharge of the client based on the client recovering more quickly due to an intervention. The focus of a process evaluation is the nature and sequence of activities carried out by nurses implementing the nursing process. A structure evaluation or audit focuses on the environment in which care is provided. Cost-effectiveness is not a type of evaluation identified by the American Nurses Association. Reference: Chapter 17: Implementing - Page 442
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? 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 normal saline. Perform vital signs and blood glucose level.
Perform vital signs and blood glucose level. Explanation: A client 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. Reference: Chapter 17: Implementing - Page 422
In the implementation step of the nursing process, which activity is the nurse's first priority? Reassess client's needs. Prioritize evaluation of care. Document nursing care. Differentiate between subjective and objective data.
Reassess client's needs. Explanation: The activities of implementation in order of priority are: (a) reassess, (b) set priorities, (c) perform nursing interventions, (d) record nursing actions. Differentiation between subjective and objective data is most associated with the assessment phase of the nursing process. Reference: Chapter 17: Implementing - Page 417
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? 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. Reassess the appropriateness of the method of instruction.
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. Reference: Chapter 17: Implementing - Page 417
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. Consult with the physical therapist to determine the client's ability. Continue assisting the client to the bathroom to ensure the client's safety. Instruct the client's family to assist the client to ambulate to the bathroom.
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. Reference: Chapter 17: Implementing - Page 428
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? Risk factors for and prevention of diabetes mellitus The cellular metabolism of glucose The severity of the client's disease Medications used to treat diabetes mellitus
Risk factors for and prevention of diabetes mellitus Explanation: 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. Reference: Chapter 17: Implementing - Page 419
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 Collaborative Surveillance Maintenance
Surveillance Explanation: Surveillance 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. Reference: Chapter 17: Implementing - Page 423
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 experienced in the needs of clients with MIs. The nurse is operating under standing orders for clients with suspected MIs. The nurse is using the standards of care for 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. Reference: Chapter 17: Implementing - Page 419
A client who has been in a vegetative state for years is scheduled for an elective surgery. The nurse is questioning whether the procedure is necessary. What is the nurse's appropriate first action? The nurse should address the concern with the surgeon. The nurse should address the concern with the hospital attorney. The nurse should address the concern with the hospital ethics committee. The nurse should address the concern with the client's family.
The nurse should address the concern with the surgeon. Explanation: The nurse should first address the concern with the surgeon who has scheduled the procedure. If the nurse still has concerns after the discussion with the surgeon, the other choices are possible courses of action. Reference: Chapter 17: Implementing - Page 416-418
Which tasks can the nurse appropriately delegate to the unlicensed assistive personnel (UAP)? Select all that apply. Record the client's intake and output. Assess the client's risk for pressure injuries. Assist the client to the bedside commode. Administer routine oral medications. Assess the client's need for education.
commode, I/O Explanation: It is crucial for the nurse to be aware of the legalities of delegation to UAPs. Appropriate delegation to a UAP would include recording intake and output and assisting the client to the bedside commode. Assessment of the client's educational needs and the risk for pressure injuries fall only under the nurse's scope of practice. Administering oral medications is not appropriate for UAPs. Reference: Chapter 17: Implementing - Page 428-432
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: skills and assistance. logistics and planning. environment and client. equipment and personnel.
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. 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. Reference: Chapter 17: Implementing - Page 422
The primary purpose of nursing implementation is to: help the client achieve optimal levels of health. identify a need for collaborative consults. improve the client's postoperative status. implement the critical pathway for the client.
help the client achieve optimal levels of health. Explanation: The purpose of the nursing implementation phase is to help the client achieve an optimal level of health. Improving the client's postoperative status and implementing the critical pathway for the client are too narrow to represent the purpose of the implementation phase, although they are purposes of specific interventions that would be implemented during this phase. Identifying the need for collaborative consults is an action the nurse would perform in the planning phase of the nursing process. Reference: Chapter 17: Implementing - Page 414