Chapter 18: Implementing
Which statement by a nurse case manager regarding this nurse's role in client care is most accurate? -"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." -"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 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.
The nurse is working with a client who is having a difficult time accepting a new diagnosis of type 2 diabetes. The nurse pulls up a chair and holds the client's hand while listening to the client's concerns. What additional type of nursing supportive intervention could the nurse provide? -Arranging for clergy to visit with the client -Arranging appointments with a specialist after the client is discharged -Providing humor in conversation to assist in alleviating stress -Teaching the client how to administer medications
Arranging for clergy to visit with the client Explanation: Supportive interventions emphasize use of communication skills, relief of spiritual distress, and caring behaviors. Psychosocial interventions focus on resolving emotional, psychological, or social problems and could include the use of humor. Coordinating interventions involve many different activities, such as acting as a client advocate and making referrals for follow-up care. Supervisory interventions refer to overseeing the client's overall health care and would include medication administration.
Which parties are essential for the nurse to include in the implementation of a client's plan of care? -Client, family, and health care provider -Client, physical therapist, and nursing staff -Client, health care provider, and hospital director -Client, surgeon, and health care provider
Client, family, and health care provider Explanation: To ensure the success of the care plan, the nurse must involve all necessary parties. It is essential that the client be involved in the client's own health care decisions. The client's family provides needed support, and the health care provider is essential to provide medical interventions. The hospital director is not necessary for the implementation of the plan of care. A physical therapist and a surgeon are not necessarily involved in every client's care.
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. -Communicate with the health care provider about additional orders. -Instruct the client to make alternate living arrangements. -Collaborate with other disciplines to revise the discharge plans.
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 health care provider 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.
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? -Medicate the client with the ordered pain medication. -Determine the frequency of pain medication. -Instruct the client in nonpharmacologic pain management. -Go to the client and assess the client's pain.
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.
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. -Reassess the appropriateness of the method of instruction. -Teach the content again utilizing the same method.
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.
The nurse is caring for a postoperative client who is receiving morphine sulfate for pain management. The nurse obtains the following vital signs: heart rate, 74 beats/min; respiratory rate, 8 breaths/min; blood pressure, 114/68 mm Hg. After reviewing the nursing care plan and health care provider orders, the nurse administers naloxone. Which would allow the nurse to initiate this action? -Algorithm -Standing orders -Protocol -Order set
Standing orders Explanation: Standing orders allow the nurse to initiate actions that ordinarily require the order of a health care provider, such as administering naloxone. An algorithm is a binary decision tree that guides stepwise assessment and intervention for a high-risk subgroup of clients. A protocol is a written plan that details nursing activities to be executed in specific situations. An order set is a preprinted set of provider orders that expedite the provider order process.
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 -Educational -Maintenance -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.
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 most appropriate 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 request that the blood transfusions be delayed until the next shift. -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 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.
The primary purpose of nursing implementation is to: -improve the client's postoperative status. -implement the critical pathway for the client. -identify a need for collaborative consults. -help the client achieve optimal levels of health.
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.
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? -unlicensed assistive personnel who is in nursing school -registered nurse -licensed practical/vocational nurse -senior student in nursing school who is present for clinical
unlicensed assistive personnel who is in nursing school Explanation: The nurse should avoid delegating this client to the unlicensed assistive personnel who is in nursing school. Suctioning and the associated evaluation of the client is within the scope of practice of the registered nurse, licensed practical/vocational nurse, and the senior student in nursing school who is present for clinical.
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? -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. -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. 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.
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 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.
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 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? -Determine the client's reaction to the medication in the past. -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.
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.
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? -Assign a home health aide to perform housekeeping duties. -Remove all the cluttered objects from the pathway to the client's bathroom. -Assist the client to identify strategies to promote safety in the home. -Instruct the client about the need to keep the walkway to the bathroom clear.
Assist the client to identify strategies to promote safety in the home. Explanation: The best way to address safety in the home is to discuss the issue with the client. Because the client has a visual deficit, clutter in the pathway to the bathroom may not be the only hazardous condition in the home. Helping the client identify safety strategies will help the client be more independent and will promote safety in the long run. Removing the cluttered objects would be important for the client's immediate safety, but would not help keep the client safe in the long run. Instructing the client to keep the walkway clear without identifying ways to do it would not keep the client safe. A home health aide could be part of the overall strategy to help protect the client, but the aide will not be present all the time to protect the client.
After instituting interventions to increase oxygenation, the client shows no signs of improvement. What is the nurse's priority action? -Determine the client's code status in case of an emergency. -Document the interventions and the result. -Reassess the client for improvement in 30 minutes. -Communicate with the health care provider for additional orders.
Communicate with the health care provider for additional orders. Explanation: If the nurse's interventions have been ineffective, the health care provider must be notified of the client's deteriorating status. The health care provider 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.
A client on the medical-surgical unit is scheduled for several diagnostic tests. The nurse is concerned that the tests will be too tiring for the client. What would be the nurse's most appropriate action? -Coordinate with the other disciplines to determine if all the tests scheduled are necessary. -Review the health care provider's progress notes to determine if any of the tests are not indicated. -Instruct the client to refuse the diagnostic tests if the client becomes too fatigued. -Coordinate with the other disciplines to schedule the tests with adequate rest for the client.
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 health care provider, the other disciplines and the nurse cannot change the orders without the health care provider 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 health care provider. 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.
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. -Give the visitors instructions to leave in 10 minutes. -Delay the instruction until the visitors leave. -Leave written information for the client to read later.
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 an adolescent 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.
Which are appropriate guidelines for the nurse to follow when delegating tasks to an unlicensed assistive personnel (UAP)? Select all that apply. -Provide feedback to the UAP after the task is completed. -Delegate tasks that involve minimal risk. -Delegate tasks that are within the UAP's scope of practice. -Provide appropriate supervision when delegating tasks. -Delegate correctly to avoid the UAP asking questions about the task.
Delegate tasks that are within the UAP's scope of practice. Delegate tasks that involve minimal risk. Provide appropriate supervision when delegating tasks. Provide feedback to the UAP after the task is completed. 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.
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 the client's refusal with hospital risk managers. -Discuss the risks and benefits of a blood transfusion with the client. -Discuss possible alternatives to a blood transfusion with the health care provider. -Discuss the client's options with other church members.
Discuss possible alternatives to a blood transfusion with the health care provider. Explanation: As coordinator of the client's care, the nurse functions as an intermediary between the health care provider and the client. In order to honor the client's wishes, the nurse would most appropriately consult with the health care provider 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.
The nurse is preparing a client for surgery when the client tells the nurse that the client no longer wants to have the surgery. How should the nurse most appropriately respond? -Discuss with the client the reasons for declining surgery. -Review with the client the risks and benefits of surgery. -Ask the client to discuss the decision with family members. -Notify the health care provider of the client's refusal.
Discuss with the client the reasons for declining surgery. Explanation: The nurse needs further information before deciding what interventions are necessary, so the most appropriate action is to determine the client's reasons for refusal. Until the information is collected, the nurse cannot decide whether reviewing the risks and benefits of surgery would be effective. It is also premature to ask the client to discuss the decision with family members. It is not appropriate to notify the health care provider until the assessment is complete.
Which is the nurse's priority question to consider prior to delegating a task to an unlicensed assistive personnel (UAP)? -What is the client's condition? -Does this task fall within the scope of a UAP? -How can I explain the task to the UAP? -How can I supervise the completion of this task?
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.
Which action is a nursing intervention that facilitates lifespan care? -Teach contraceptive options for planned pregnancy. -Identify coping strategies for the family that have worked in the past. -Educate family members about normal growth and development patterns. -Explore factors that could motivate adolescent members of the family to engage in risky behaviors.
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.
Which is an independent (nurse-initiated) action? -Executing health care provider orders for a catheter -Meeting with other health care professionals to discuss a client -Administering medication to 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 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 health care provider's orders, such as for catheterization and medication administration, are dependent nursing interventions. Meeting with other health care professionals describes collaborative care.
Which is an independent (nurse-initiated) action? -Executing health care provider orders for a catheter -Helping to allay a client's fears about surgery -Administering medication to a client -Meeting with other health care professionals to discuss a client
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 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 health care provider's orders, such as for catheterization and medication administration, are dependent nursing interventions. Meeting with other health care professionals describes collaborative care.
Which action should the nurse take to ensure that an unlicensed assistive personnel (UAP) understands the instructions to perform a delegated task? -Request that the UAP place the steps of the task in the framework of the nursing process. -Ask another UAP to observe and assist the UAP in performing the task. -Inform the UAP of the importance of following each step listed in the procedure manual. -Instruct the UAP to repeat the instructions to be sure the nurse has communicated clearly.
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.
Which statement best explains why continuing data collection is important? -It meets current standards of care. -It is the most efficient use of the nurse's time. -It enables the nurse to revise the care plan appropriately. -It is difficult to collect complete data in the initial assessment.
It enables the nurse to revise the care plan appropriately. Explanation: Continuous data collection ensures that the nurse has the most current client data to evaluate, which allows for updating the care plan as needed. A complete assessment is performed on admission, but the client's condition is always changing. The purpose of continued data collection is to provide good client care; it does not relate directly to efficiency of nursing care. While continuous data collection meets standards of care, it is not the primary reason for ongoing assessments.
The nurse ascertains that a client is failing to follow the plan of care that was collaboratively developed. Further investigation determines that the plan of care is not appropriate for this client. What is the nurse's next step in correcting this problem? -Provide information to the client on the benefits of complying with the plan of care. -Ask the client's family to assist the client in following the plan of care. -Discuss the desired outcomes with the client and the importance of the outcomes. -Make changes in the plan of care based upon assessment data.
Make changes in the plan of care based upon assessment data. Explanation: A plan of care that is inappropriate for the client requires a change in the plan of care, not a change in the client. In situations when the plan of care is appropriate, the nurse must evaluate factors that contribute to the client's failure to comply. Such factors include lack of family support, lack of understanding of the benefits of compliance, low value attached to the outcomes and related interventions, and adverse or emotional effects of treatment.
The health care provider 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? -Explain to the client the benefits of ambulation. -Ambulate the client and medicate later. -Emphasize to the client the importance of following the treatment plan. -Medicate the client and wait to ambulate later.
Medicate the client and wait to ambulate later. Explanation: It is most appropriate to manage the client's pain first. The client will be able to ambulate more easily and it is not necessary to cause the client further pain. Ambulating first considers the needs of the nurse, not the client. The client has not indicated misunderstanding of benefits or the importance of 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 the client's care. -Reassure the client that the nurse knows when to perform hand hygiene. -Inform the client that it is not necessary to wash hands before vital signs. -Tell the client that gloves are required for this procedure.
Praise the client for taking an active role in the client's care. Explanation: Clients should be empowered to take responsibility for self-care. All clients should be taught that they have the power to question any part of their care. The nurse would appropriately praise the client. It is necessary to wash hands before taking vital signs; gloves are not required for the procedure. Telling the client that the nurse knows when to perform hand hygiene is disrespectful of the client's concern.
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. -Instruct the client that pain medication is available at regular intervals. -Perform additional nonpharmacological pain interventions. -Notify the health care provider that the client has required pain medications.
Reassess the client to determine the effectiveness of the interventions. Explanation: After implementing any interventions (such as pain medication or any nonpharmacological pain control method, such as splinting the incision), the nurse must always reassess the client to determine the effectiveness of the interventions. It is more likely that the pain medication is available on an as-needed basis rather than at regular intervals; in any case, informing the client of the availability of pain medication is of lower priority than reassessing the client to determine the effectiveness of the interventions performed. There is no need to inform the health care provider that the client has required pain medication; the health care provider anticipated the client needing pain medication, which is why the health care provider ordered the medication for the client to begin with. After evaluating the effectiveness of the implemented interventions, if the nurse finds that they have been ineffective, then the nurse would then revise the plan and include additional interventions, including, possibly, other nonpharmacological pain interventions.
A nurse in the intensive care unit (ICU) has been assigned to care for a client who was seriously injured during a gang rape. The nurse was raped 6 months ago and fears being too upset to care for the client properly. How should the nurse deal with the assignment? -Recognize that the nurse may be faced with this issue again and care for the client. -Recognize the nurse's own limitations and ask another nurse to assist if the nurse becomes too emotional. -Recognize the issue and care for the client to the best of the nurse's ability. -Recognize the nurse's own limitations and ask for another nurse to be assigned.
Recognize the nurse's own limitations and ask for another nurse to be assigned. Explanation: The nurse should keep the client's best interests in mind. If the nurse feels that the nurse's emotional state would compromise the client's care, the best course would be for the nurse to request a different assignment. The other courses of action leave the possibility that the client's care could be compromised.
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? -Inform the client that the blood pressure medication will have to be changed. -Report the findings to the health care provider for further plans. -Reinforce the instructions for the treatment regimen to the client. -Interview the family to determine if the client is giving accurate information.
Report the findings to the health care provider for further plans. Explanation: The nurse should report the findings to the health care provider 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 health care provider's decision.
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? -Medications used to treat diabetes mellitus -The severity of the client's disease -Risk factors for and prevention of diabetes mellitus -The cellular metabolism of glucose
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.
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 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.
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.
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 an architect. -The client is married. -The client is male. -The client is blind. -The client denies the need for education.
The client is blind. The client denies the need for education. 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.
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 tells the nurse that the client's spouse will handle the care. -The client asks the nurse to repeat the instructions. -The client discusses the specifics of what was taught during the session. -The client verbalizes understanding of the instructions. -The client is able to answer the nurse's questions.
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. Explanation: After an intervention is implemented, the nurse must assess the effectiveness of the intervention. The client stating an understanding of the instructions gives the nurse an indication that learning has taken place. Asking the client questions and receiving the correct answers is an excellent way to judge the client's knowledge. The client asking for the nurse to repeat the instructions shows that the client does not have a clear understanding. The client's statement that the spouse will handle the care signals that the client is not ready to learn at this time. The client's ability to discuss the specifics of the material suggests that learning has taken place.
The registered nurse is working with an unlicensed assistive personnel. Which client should the nurse not delegate to the unlicensed assistive personnel? -The client who needs vital signs taken following infusion of packed red blood cells. -The client with continuous pulse oximetry who requires pharyngeal suctioning. -The client who requires assistance dressing in preparation for discharge. -The client who is pleasantly confused and requires assistance to the bathroom.
The client with continuous pulse oximetry who requires pharyngeal suctioning. Explanation: The nurse needs to perform the pharyngeal suctioning of the client with continuous pulse oximetry. This client requires the nurse to evaluate the client's response in pulse oximetry to the suctioning. The nurse can delegate the other clients to the unlicensed assistive personnel.
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 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 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. 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.
The nurse is discussing dietary options with a client who is upset due to not being able to have foods the client previously enjoyed. The nurse states, "You may not be able to have steak, but you can have grilled salmon or grilled chicken. Which do you prefer?" What is the purpose for giving the client an option? -To help the client adhere to the plan -To give the client the opportunity to actively participate in care -To save the client the trouble of looking in the menu -To encourage the client to make a healthy food choice
To give the client the opportunity to actively participate in care Explanation: Giving clients options allows them to actively participate in their own care, which is empowering. Although giving the client options might improve the client's adherence to the plan, this is not the primary purpose. The purpose of giving the client options is not to save the client the trouble of looking in the menu or to encourage the client to make a healthy food choice.
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 -Process -Outcome -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.
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? -registered nurse -senior student in nursing school who is present for clinical -unlicensed licensed personnel -licensed practical/vocational nurse
unlicensed licensed personnel Explanation: The nurse should avoid delegating the dressing change to the unlicensed assistive personnel. The dressing change is within the scope of practice of the registered nurse, licensed practical/vocational nurse, and the senior student in nursing school.
