Chapter 17 - Implementing

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."

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 has a nursing diagnosis of Possible Spiritual Distress. What is the most appropriate nursing intervention?

Discuss spirituality with the client.

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?

Encourage the client to provide as much self-care as possible.

In the implementation step of the nursing process, a nurse is to utilize certain activities to be effective in the care of a client. Which activity is the priority?

Reassess client's needs.

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.

Nurses use the Nursing Outcomes Classification when choosing nursing goals for clients. What are the goals of the research that is behind the Nursing Outcomes Classification (NOC)? Select all that apply.

To evaluate the validity and usefulness of the classification in clinical field testing To identify, label, and validate nursing-sensitive client outcomes and indicators To define and test measurement procedures for the outcomes and indicators

In order to successfully implement the plan of care, what parties are essential for the nurse to include?

client, family, and physician

standing orders

document that details the nursing care to be implemented in specific nursing situations, frequently when a physician is not present; may expand scope of nursing responsibilities

Coordinator

someone whose task is to see that work goes harmoniously

direct care

when we are working directly with the patient

A nurse case manager is explaining the role of a case manager to a group of nursing students. One student asks if the case manager misses providing client care. What is the case manager's best response?

"I provide indirect care to my clients by coordinating their treatment with other disciplines."

A nurse is preparing to implement interventions for a client based on the client's plan of care. To ensure the nurse is successful in implementing the plan, which question would be important for the nurse ask himself/herself? Select all that apply.

"Is the client prepared for what needs to be done?" "Do I have all the necessary supplies and equipment needed?" "Do I have the skills to perform the interventions?" "Can I do the intervention alone or do I need help?" "Do I know what to do if something happens?"

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."

The client tells the nurse, "I think the nurse last night may have given me the wrong medication, but I was afraid to say anything." What is the nurse's most appropriate response?

"You should always speak up if you have any questions about your care."

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.

Critical Thinking in Implementing

Assess: before any action Reassess: determine the response Revise: as indicated Record:

The home health nurse caring for a client with limited eyesight notes that the client's route to the bathroom is cluttered. What is the most effective way for the nurse to ensure the client's long-term safety?

Assist the client to identify strategies to promote safety in the home.

The nursing is caring for several clients. Which intervention can the nurse direct the unlicensed assistive personnel (UAP) to perform?

Bathe a client with stable angina who has a continuous IV infusing.

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?

Client with a high fever receiving intravenous fluids, antibiotics and oxygen

After instituting interventions to increase oxygenation, the client shows no signs of improvement. What is the nurse's priority action?

Communicate with the physician for additional orders.

A nurse is preparing to educate a client about self-care after cataract surgery. Which of the following would the nurse do first?

Determine the client's willingness to follow the regimen.

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.

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.

Nurses perform many independent nursing actions when caring for clients. Which action is considered an independent (nurse-initiated) action?

Helping to allay a client's fears about surgery

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 restaraunt 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.

As the nurse bathes a client, she notes his skin color and integrity, his ability to respond to simple directions, and his muscle tone. Which statement best explains why such continuing data collection is so important?

It enables the nurse to revise the care plan appropriately.

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 caring for Mr. H., a 35-year-old man who is hospitalized following a motorcycle accident. He has a traumatic brain injury. The nurse is working with Mr. H. on self-care behaviors. The following would help the nurse to assess the success of the nursing interventions except which of the following?

Model self-care behaviors for the client.

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 nurse is coordinating care for the client with continuous pulse oximetry who requires pharyngeal suctioning. Which staff member should the nurse avoid delegating the task of suctioning?

Nursing assistant who is a nursing student

A nurse is preparing to implement interventions identified on the clent's plan of care. Before implementing any intervention, which action would the nurse take first?

Reassess the client to determine if the action is needed.

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 postoperative client who is receiving morphine sulfate for pain management. The nurse obtains the following vital signs: HR 74, RR 8, BP 114/68. After reviewing the nursing care plan and physician orders, the nurse administers naloxone. What would allow the nurse to initiate this action?

Standing orders

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.

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.

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

finances of the client

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 nurse is caring for Mr. M., a 48-year-old man with congestive heart failure. The nurse manager informs the nurse that Mr. M. 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 evaluation

The nurse is discussing diabetes mellitus with the family members of a client recently diagnosed. In order to promote the health of the family members, what would be the most important information for the nurse to include?

risk factors and prevention of diabetes mellitus

An 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.

transporting the infant to the mother's room according to hospital policy assisting the client with personal hygiene needs and ambulation

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 his care.

When caring for a client in the emergency room who has presented with symptoms of a (MI) myocardial infarction, the nurse orders laboratory tests and administers medication to the client before the physician has examined the client. In order for the nurse to be operating within the nurse's scope of practice, what conditions must be present?

The nurse is operating under standing orders for clients with MIs.

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.

An 84-year-old male has been admitted to the hospital several times in the past few months for exacerbations of chronic obstructive pulmonary disease (COPD) and elevated blood glucose. Which statement by the client could help identify the most likely reason for the changes in his health status?

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

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

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.

The nurse is preparing a client for surgery when the client tells the nurse that he no longer wants to have the surgery. How should the nurse most appropriately respond?

Discuss with the client the reasons for declining surgery.

The nurse is caring for a client who does not speak the same language. The unlicensed assistive personnel (UAP) speaks the same language as the client. What parts of communicating with the client could the nurse appropriately delegate to the UAP? Select all that apply.

Ask the client questions regarding personal care needs. Orient the client and family to the room, including the call light button.

Which nursing intervention is appropriate for a risk nursing diagnosis? Select all that apply.

Prevent the problem. Reduce or eliminate risk factors. Monitor the client's status.

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.

A nurse who is experienced caring only for well babies is assigned to the newborn intensive care nursery (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 she does not have the experience to properly care for this client.

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

The nurse in a Burn Intensive Care Unit (BICU) is caring for a 3-year-old boy who was burned with scalding hot water. He has burns covering 75 percent of his body. His condition is critical but stable. At 1000, the nurse reassesses the client and finds that he is agitated and pulling at his endotracheal tube. What would be the nurse's priority?

ensuring that the endotracheal tube is secure

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 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

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

Which role is a responsibility of the nurse in the nurse-health care team relationship? Select all that apply.

Serve as a liaison between the client and family and the health care team. Coordinate the inputs of the multidisciplinary team into a comprehensive plan of care.

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 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.

indirect care

treatment performed away from the patient but on behalf of a patient or group of patients

Nursing Interventions

Activities that the nurse plans and implements to help the patient achieve identified outcomes

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?

Surveillance

A busy nurse is working with an unlicensed assistive personnel (UAP). What tasks can the nurse appropriately delegate to the UAP? Select all that apply.

Assist the client to the bedside commode. Record the client's intake and output.