FN - Unit 2 - Chapter 18: Implementing

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: equipment and personnel. environment and client. logistics and planning. skills and assistance.

equipment and personnel. 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.

The primary purpose of nursing implementation is to: improve the client's postoperative status. identify a need for collaborative consults. help the client achieve optimal levels of health. implement the critical pathway for the client.

help the client achieve optimal levels of health. 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.

A nurse follows set guidelines for administering pain medication to clients in a critical care unit. This nurse's authority to initiate actions that normally require the order or supervision of a health care provider is termed: protocols. nursing interventions. collaborative orders. standing orders.

standing orders. Standing orders empower the nurse to initiate actions that ordinarily require the order or supervision of a health care provider, such as pain medication administration based on specific criteria. Protocols are written plans that detail the nursing activities to be executed in specific situations; these include routine nursing care and standing orders. Nursing interventions refer to care administered by the nurse and can be dependent or independent in nature. Collaborative orders may include suggested care strategies from other health care personnel such as the physical therapist.

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." "I can learn about evidence-based practice by reading professional nursing journals." "Nursing interventions should be supported by a sound scientific rationale." "The Agency for Healthcare Research and Quality is a resource for evidence-based practice."

"I must conduct research to validate the usefulness of my nursing interventions." Nursing interventions should be supported by a sound scientific rationale; however, nurses do not need to personally conduct research to establish the rationale for nursing interventions. Nurses can learn about evidence-based practice by reading professional nursing journals, attending nursing workshops, and consulting evidence-based practice resources, such as the Agency for Healthcare Research and Quality.

Which statement by a nurse case manager regarding this nurse's role in client care is most accurate? "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." "I provide a critical service that is necessary for financial reimbursement." "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." 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.

A client with diabetes who has been closely following the prescribed plan of care for over a year is being seen at an outpatient facility. The client has not brought a log of daily glucose checks and tells the nurse, "I haven't been doing them regularly." What is the nurse's most therapeutic statement to the client? "It is extremely important to your health to strictly follow your plan of care." "It seems like you are having difficulty with your care regimen." "Should I arrange for a home health nurse to coordinate your care?" "Should I instruct your family to do the glucose checks for you?"

"It seems like you are having difficulty with your care regimen." The nurse's open-ended statement acknowledging that the client is having difficulty with the care regimen encourages the client to discuss what has occurred that has caused the client to not manage the diabetes as was previously done. The statement reminding the client that health care is important will discourage the client to freely discuss any problems. A home health nurse or instructions given to the family may be indicated, but not until the client has verbalized the reasons why the care regimen has not been followed.

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? "I will report your concerns to the nurse manager." "I will discuss your concerns with the night nurse." "You should always speak up if you have any questions about your care." "You always have the right to refuse any medication or treatment."

"You should always speak up if you have any questions about your care." The priority is to empower the client into taking an active role in the client's care, so the nurse should tell the client to feel free to ask questions. The client does have the right to refuse, but this does not address the issue. Speaking to the nurse manager or the night nurse does not help the client deal with a similar situation in the future.

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? A client with a high fever receiving intravenous fluids, antibiotics, and oxygen An older adult with pneumonia who is being discharged to the son's home tomorrow A middle-aged client who had abdominal surgery 3 days ago and is ambulating in the hall An adult client who is being treated for kidney stones

A client with a high fever receiving intravenous fluids, antibiotics, and oxygen 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.

Which type of nursing intervention is oxygen administration and why is it considered to be so? A dependent nursing intervention, because oxygen is considered a drug that requires a health care provider's order A collaborative nursing intervention, because it is ordered by the respiratory therapist An independent nursing intervention, because nurses have the necessary skill to administer oxygen An interdependent intervention, because health care providers, nurses, and respiratory therapists have the necessary skill to administer oxygen

A dependent nursing intervention, because oxygen is considered a drug that requires a health care provider's order Oxygen administration is a dependent nursing intervention because it requires a health care provider's order. Independent nursing interventions are autonomous actions based on scientific rationale that a nurse executes to benefit the client in a predictable way related to the nursing diagnosis and expected outcomes. Nursing-initiated interventions, such as teaching, providing fluids, and assisting with guided imagery, do not require a health care provider's order. Collaborative and interdependent are not types of nursing interventions.

Which examples of nursing actions involve direct care of the client? Select all that apply. A nurse counsels a young family who is interested in natural family planning. A nurse massages the back of a client while performing a skin assessment. A nurse arranges for a consultation for a client who has no health insurance. A nurse helps a client in hospice fill out a living will form. A nurse arranges for physical therapy for a client who had a stroke.

A nurse counsels a young family who is interested in natural family planning. A nurse massages the back of a client while performing a skin assessment. A nurse helps a client in hospice fill out a living will form. 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.

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 Teaching the client how to administer medications Providing humor in conversation to assist in alleviating stress Arranging appointments with a specialist after the client is discharged

Arranging for clergy to visit with the client 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.

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. Interview the client as part of the admission assessment. Provide education to the client, including discharge instructions. Ask the client questions regarding personal care needs. Demonstrate and teach new caregiving procedures to the family. Counsel the client about making adjustments to a new medical condition. Orient the client and family to the room, including the call light button.

Ask the client questions regarding personal care needs. Orient the client and family to the room, including the call light button. Delegation to a UAP requires knowledge of the registered nurse (RN) role and what tasks can be legally delegated. The RN can delegate asking clients questions about personal care needs and orientation to the room (for example, the call light button). It is inappropriate to have the UAP interview the client as part of the admission assessment, provide education to the client or family, or counsel the client. Those duties are legally the role of the RN and would be most appropriately addressed with a the assistance of a professional interpreter.

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. Consult with the health care provider for additional pain medication. Discuss the frequency of pain medication administration with the client. Assist the client to reposition and splint the incision.

Assess the client to determine the cause of the pain. 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.

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. Determine the client's reaction to the medication in the past. Ask the client to verbalize the purpose of the medication. Tell the client to report any side effects experienced.

Assess the client's blood pressure to determine if the medication is indicated. 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.

Which nursing action can be categorized as a surveillance or monitoring intervention? Auscultating of bilateral lung sounds Providing hygiene Administering a paracetamol tablet Use of therapeutic communication skills

Auscultating of bilateral lung sounds 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 health care provider 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.

A nurse is catheterizing a client. Which scenario demonstrates steps the nurse would take to ensure client respect and privacy? Verify the client's identifiable information, explain the procedure to the family, and pull the privacy curtain to allow the client to feel comfortable in having family close by. Close the door to the room, explain the procedure to the client, and cover all areas of the client, only exposing the area for catheterization. Ask family members to leave the room briefly, close the door, and ask the client if he or she would like a sheet to cover oneself. Bring in another nurse to provide support and prevent questionable behaviors, explain the procedure to the client, and close the door and privacy curtain prior to beginning the procedure.

Close the door to the room, explain the procedure to the client, and cover all areas of the client, only exposing the area for catheterization. It is important to think about the environment for each intervention. Pay special attention to respecting the client's privacy and dignity; for example, close the door to the room or pull the drapes between the beds. To demonstrate respect, the procedure should be explained to the client and all areas except the sterile area should be covered to protect modesty and privacy. Asking another nurse to assist is helpful, but not required and may make the client feel awkward. There is no need to discuss with the family, because the client does not have any cognitive issues.

A client being treated for myasthenia gravis at home tells the nurse, "This medicine is so expensive. I have only been taking half of what the doctor ordered." How would the nurse most effectively meet this client's need? Collaborate with other disciplines to determine the best way to meet the client's medication requirements. Reinforce to the client and family the necessity of taking all medication as ordered to stabilize the client's condition. Inform the health care provider of the need to prescribe a less expensive medication for the client's condition. Instruct the client that some pharmaceutical companies have programs to help with medication expenses.

Collaborate with other disciplines to determine the best way to meet the client's medication requirements. In order to meet the client's needs, it is most important to involve other disciplines in the client's care to utilize all available resources. Reinforcing the importance of the medication does not solve the financial problem. It may be necessary for the health care provider to prescribe a less expensive medication, but other options should be considered to address the holistic needs of the client. Some pharmaceutical companies have programs to help with medication expenses, but the client will need information in order to apply for the programs.

A client in the last stages of pancreatic cancer tells the nurse, "I am tired of fighting. I am ready to die." What is the nurse's best action? Collaborate with other disciplines to plan end-of-life care for the client. Research other treatment options available for the client. Remind the client that positive thoughts are essential for recovery. Ask if the client would like to speak with a spiritual adviser.

Collaborate with other disciplines to plan end-of-life care for the client. The client has indicated an acceptance of the terminal condition. To respect the client's wishes, the nurse should involve other disciplines, such as hospice care, in planning for the client's needs. The client has not asked the nurse for other treatment options, so researching other options is not honoring the client's wishes. Reminding the client to think "positive thoughts" dismisses the seriousness of the client's concerns. Speaking with a spiritual adviser might be part of the collaborative care, but it would not address all the client's needs.

Discharge plans for a client with a mental health disorder include living with family members. The nurse learns that the family is no longer willing to allow the client to live with them. What is the nurse's most appropriate action? Collaborate with other disciplines to revise the discharge plans. Instruct the client to make alternate living arrangements. Communicate with the health care provider about additional orders. Inform the family that it is not possible to change the discharge plans.

Collaborate with other disciplines to revise the discharge plans. 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.

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. Communicate with the health care provider for additional orders. Determine the client's code status in case of an emergency.

Communicate with the health care provider for additional orders. 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 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? 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. Collaborate with other health care professionals about the client's treatment. Change the nursing care plan.

Identify what barriers the client feels are preventing adherence with the plan. 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.

The nurse is preparing a client with a bowel obstruction for emergency surgery. Which intervention has the highest priority for this client? Discuss discharge plans with the client. Inform the client what to expect after the surgery. Instruct the client and family in wound care. Teach the client about dietary restrictions during recovery.

Inform the client what to expect after the surgery. 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.

Which action should the nurse take to ensure that an unlicensed assistive personnel (UAP) understands the instructions to perform a delegated task? Instruct the UAP to repeat the instructions to be sure the nurse has communicated clearly. Request that the UAP place the steps of the task in the framework of the nursing process. Inform the UAP of the importance of following each step listed in the procedure manual. Ask another UAP to observe and assist the UAP in performing the task.

Instruct the UAP to repeat the instructions to be sure the nurse has communicated clearly. Instruct the UAP to repeat the nurse's instructions to be sure the nurse has communicated them clearly. The UAP must be clear on the difference between nursing tasks and the nursing process, as the nursing process structures care delivered by the registered nurse. Although it is important for the UAP to follow procedure manuals, it is important that the registered nurse is clear on the UAP's understanding of the steps through direct observation or discussions. It is not correct to ask another UAP to observe and assist the UAP in performing the task.

The nurse 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? Make changes in the plan of care based upon assessment data. Ask the client's family to assist the client in following the plan of care. Provide information to the client on the benefits of complying with 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. 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? Medicate the client and wait to ambulate later. Ambulate the client and medicate later. Emphasize to the client the importance of following the treatment plan. Explain to the client the benefits of ambulation.

Medicate the client and wait to ambulate later. 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.

A nurse is administering metformin to a client who has a new onset of diabetes mellitus type 2. Which step should the nurse consider a priority on the nursing care plan? Restrict intake of foods and fluids. Monitor for noncompliance. Monitor for lactic acidosis Administer B12 injections

Monitor for lactic acidosis In this scenario, the nurse is administering a medication. Because an action is being carried out, this is the implementation step of the nursing process. Following the administration of medication, the nurse should monitor the client for lactic acidosis as well as side effects of the medication. Restricting the client's food and fluids while the client is on metformin is only suggested when the client is preparing for a procedure requiring the client to be NPO. B12 injections may be indicated in the future as treatment has been established. Likewise, it is too early in the treatment plan to monitor for noncompliance.

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? Process Structure Outcome Cost-effectiveness

Outcome 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.

An indwelling urinary catheter has been ordered for a client experiencing urinary retention after surgery. When the nurse enters the room to place the catheter, the client reports voiding in the bathroom. Which is the nurse's most appropriate action? Insert the urinary catheter as ordered to relieve the urinary retention. Reassess whether the client still needs the urinary catheter. Instruct the client that the catheter is essential to check for urinary retention. Inform the client that the catheter will no longer be necessary.

Reassess whether the client still needs the urinary catheter. Before any intervention is implemented, the nurse should assess whether the intervention is still indicated. In this case, the client's report of voiding makes it all the more essential that the nurse assess whether the client is still retaining urine before inserting the catheter. The nurse should not tell the client the catheter is necessary or unnecessary until after the nurse has completed the assessment and confirmed whether it is necessary.

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 the nurse's own limitations and ask for another nurse to be assigned. 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. 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? 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. Inform the client that the blood pressure medication will have to be changed.

Report the findings to the health care provider for further plans. 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 client reports right knee pain of 6/10 on the pain scale and requests medication. The nurse assesses and flushes the intravenous site. Which type of intervention skill is the nurse using? Interpersonal skill Intellectual skill Technical skill Mechanical skill

Technical skill Technical skills are used to carry out treatments and procedures, such as assessing and flushing an intravenous site. Nurses learn the specific skills through clinical practice. Intellectual skills include the ability to explain complex disease processes and treatment regimens to a client. Interpersonal skills, such as communication, allow the nurse to establish strong relationships and build trust with the client. Mechanical skills are not among the skills nurses need.

Which examples are essential components for delegating nursing care to an unlicensed assistive personnel (UAP)? Select all that apply. The UAP has sufficient knowledge and skill for completing the task. The nurse has clearly communicated instructions to the UAP. The UAP can verbalize what information to report to the nurse. The nurse seeks input from the UAP in planning the client's care for the shift. The UAP evaluates the client's response after implementing the task and then reports findings to the nurse.

The UAP has sufficient knowledge and skill for completing the task. The nurse has clearly communicated instructions to the UAP. The UAP can verbalize what information to report to the nurse. Essential components of effective delegation include delegating the task to a person with sufficient knowledge and skill for completing the task; communication of clear and specific instructions by the nurse to the UAP; and validation of understanding by the UAP regarding information to be reported to the nurse. Planning and evaluating remain the responsibility of the nurse and are not delegated to UAP.

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 who requires assistance dressing in preparation for discharge. The client with continuous pulse oximetry who requires pharyngeal suctioning. The client who is pleasantly confused and requires assistance to the bathroom.

The client with continuous pulse oximetry who requires pharyngeal suctioning. 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 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. The client is watching television. The client's family asks if the client is going to be okay.

The client's respiratory rate decreases. The client states, "I can breathe easier now." The client's oxygen saturation level increases. When reassessing the client after implementing interventions to increase oxygenation, the nurse would look for a decrease in respiratory rate to a more normal rate and an increase in the oxygen saturation level. The client's subjective statement of breathing easier would also indicate effectiveness. The client watching television and the client's family's statement do not indicate anything about oxygenation status.

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 health care provider 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 using the standards of care for clients with MIs. The nurse is operating under standing orders for clients with suspected MIs. The nurse is experienced in the needs of clients with MIs. The nurse is ordering what the health care provider usually orders.

The nurse is operating under standing orders for clients with suspected MIs. For the nurse to administer medications or order laboratory tests, the nurse must have a health care provider'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 health care provider's order.

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. 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.

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 inform the charge nurse that the nurse does not have the experience to properly care for this client. The nurse should ask another nurse who was previously assigned to the client for instruction. The nurse should request that the blood transfusions be delayed until the next shift. The nurse should recognize the necessity of the assignment and provide care to the best of the nurse's ability.

The nurse should inform the charge nurse that the nurse does not have the experience to properly care for this client. The nurse should 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 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 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.

What are the goals of the research that is behind the Nursing Outcomes Classification (NOC) system? Select all that apply. To identify, label, and validate nursing-sensitive client outcomes and indicators To teach decision making To ensure appropriate reimbursement for nursing services To communicate nursing to non-nurses To evaluate the validity and usefulness of the classification in clinical field testing To define and test measurement procedures for the outcomes and indicators

To identify, label, and validate nursing-sensitive client outcomes and indicators To evaluate the validity and usefulness of the classification in clinical field testing To define and test measurement procedures for the outcomes and indicators The goals of research behind the NOC are to identify, label, validate, and classify nursing-sensitive client outcomes and indicators; evaluate the validity and usefulness of the classification in clinical field testing; and define and test measurement procedures for the outcomes and indicators. This research continues in an effort to develop a common nursing language to optimize the design and delivery of safe, high-quality, and cost-effective care. Teaching decision making and ensuring proper reimbursement are not goals of the NOC. Communicating nursing to non-nurses is a goal of the Nursing Interventions Classification (NIC).

An 87-year-old client has been admitted to the hospital several times in the past few months for exacerbations of chronic obstructive pulmonary disease and elevated blood glucose levels. Which statement by the client could help identify the most likely reason for the changes in the client's health status? "My daughter has been staying with me the past few weeks." "I asked my neighbors to help me with my yard work." "My wife's been gone for about 7 months now." "I sort my medication into an organizer every week."

"My wife's been gone for about 7 months now." The client's loss may be affecting how well the client is able to provide self-care. The client may be depressed and questioning the benefits of the health care regimen, or the client may have depended on the wife to help with health care and no longer has the ability to take care of himself. Assessment of the client allows the nurse to alter the plan of care to meet the client's needs. The statements concerning having a family member staying with the client, having help with the yard work, and sorting medications into an organizer all indicate factors that would improve the client's ability to provide self-care, not decrease it.

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? "It is a habit that nurses develop in school." "It is a hospital policy to reduce the potential for errors." "We ask your name to ensure that we are treating the right client." "We ask your name to show that we respect your rights."

"We ask your name to ensure that we are treating the right client." The primary reason for asking the client to state the client's name is to ensure that the nurse is dealing with the correct client. Asking the client to state the client's name is a habit that should be developed in nursing school, but that is not the reason nurses ask clients for their names. It is not just a hospital-specific policy to ask the client for the client's name, but it is a step that is used in all client care situations. Respecting clients' rights is important but that is not why nurses ask for their names.

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 Changing a client's intravenous (IV) fluid from normal saline to 5% dextrose Administering a beta-adrenergic blocker to a new client whose blood pressure is high on admission assessment Changing a client's advance directive after the prognosis has significantly worsened

Administering a glycerin suppository to a constipated client who has not responded to oral stool softeners Standing orders and protocols often surround the management of bowel elimination. Modification of a client's IV fluid or administration of a new antihypertensive are client-specific interventions that are health care provider initiated. The care team cannot independently change a client's advance directive.

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. If the nurse suspects a client does not understand instructions, the first step is to assess the client's understanding. The most effective way to do that is to have the client repeat the client's understanding of the instructions. The other steps might be interventions that the nurse would institute after determining the client's needs.

The surgeon is insisting that a client consent to a hysterectomy. The client refuses to make a decision without the consent of the client's spouse. What is the nurse's best course of action? Remind the client that the client is responsible for the client's own health care decisions. Ask the client whether the client is afraid that the spouse will be angry. Ask the surgeon to wait until the client has had a chance to talk to the spouse. Inform the surgeon that the nurse will not sign the informed consent form.

Ask the surgeon to wait until the client has had a chance to talk to the spouse. It is important to consider the client's wishes, so the nurse should advocate for the client and ask the surgeon to wait until the client has talked to the spouse. Telling the client that the client is responsible for the client's own health care decisions does not respect the client's desire to consult the spouse. The client has not expressed being fearful of the spouse. Informing the surgeon that the nurse will not sign the consent form will not satisfy the client's request.

The 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? Remove all the cluttered objects from the pathway to the client's bathroom. 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. Assign a home health aide to perform housekeeping duties.

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

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. Initial assessment of the mother after birth of the infant Assisting the client with personal hygiene needs and ambulation Assisting and teaching the client to breastfeed the infant Providing routine discharge instructions related to infant care Transporting the infant to the mother's room according to hospital policy

Assisting the client with personal hygiene needs and ambulation Transporting the infant to the mother's room according to hospital policy It is essential when delegating duties that the registered nurse (RN) is aware the nurse's role and what duties can be delegated. The nurse also must be aware of the training and the competence of the UAP. The nurse could appropriately delegate assisting with personal hygiene needs, ambulation, and transporting the infant to the mother's room according to hospital policy. Assessment is the role of the RN and cannot be delegated. Teaching, including breastfeeding education and discharge instructions, is also the role of the RN and cannot be delegated.

The nurse is caring for several clients. Which intervention can the nurse direct the unlicensed assistive personnel (UAP) to perform? Take the vital signs of the client who just returned from surgery. Feed a client who is eating for the first time following an ischemic stroke. Bathe a client with stable angina who has a continuous IV infusing. Assist the client who is ambulating the first time since hip replacement surgery.

Bathe a client with stable angina who has a continuous IV infusing. The nurse can instruct the UAP to bathe the client with stable angina who has a continuous IV infusing. The other clients require the clinical reasoning skills of the nurse to evaluate their response.

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 Preparation of insulin for the diabetic client with an elevated blood glucose level Ambulation of the client with a history of falls for the first time after surgery Insertion of a urinary catheter in a client with benign prostatic hypertrophy

Bed bath for the newly admitted client who has multiple skin lesions The safest delegation is to have the UAP bathe the client with skin lesions and report any abnormal findings to the nurse. Preparing insulin is outside of the UAP's scope of practice. The UAP may have the skills to insert an indwelling catheter and ambulate clients, but the clients involved each have qualifiers that complicate the tasks.

A nurse is developing a plan of care for a client and determines appropriate outcomes and interventions for this client. Which variable would be most appropriate for the nurse to address to ensure that the care plan meets the client's needs? Select all that apply. Client's ability to participate Client's developmental stage Client's cultural background Client's socioeconomic status Client's gender

Client's ability to participate Client's developmental stage Client's cultural background Client's socioeconomic status Ideally, the client is primary in determining how nursing interventions are implemented. Successful nurses modify their nursing actions according to the client's changing ability, willingness to participate in the care plan, previous responses to nursing interventions, and progress toward achieving goals or outcomes. Other important variables are the client's developmental stage, psychosocial background (including socioeconomic status), and culture. Gender is not considered a variable that would affect the care plan.

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, health care provider, and hospital director Client, physical therapist, and nursing staff Client, surgeon, and health care provider

Client, family, and health care provider 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.

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 health care providers wrote orders to ambulate the client, whereas another health care provider ordered strict bed rest for the client. How would the nurse most appropriately remedy this conflict? Assess the client to determine whether the client is capable of ambulation. Instruct the client to ask the health care providers for clarifications of instructions. Communicate with the health care providers to coordinate their orders. Collaborate with the physical therapist to determine the client's ability.

Communicate with the health care providers to coordinate their orders. 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 health care providers 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 health care providers's orders have to be clarified first.

Which is the priority question for the nurse to consider before implementing a new intervention? Does this treatment make sense for this client? How much experience do I have with this treatment? What equipment do I need? Will I need someone to assist me?

Does this treatment make sense for this client? All of these questions are important, but the priority is whether the treatment makes sense for the client. If not, answering the other questions is unnecessary.

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? Delay the instruction until the visitors leave. Give the visitors instructions to leave in 10 minutes. 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. 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.

A nurse is preparing to educate a client about self-care after cataract surgery. Which should the nurse do first? Determine the client's willingness to follow the regimen. Identify changes from the baseline. Ensure health care provider approval for the education plan. Instruct the unlicensed assistive personnel on what to teach the client.

Determine the client's willingness to follow the regimen. The prerequisite to health education about self-care after cataract surgery is the client's willingness to follow the regimen. Once a nurse is aware of the client's readiness for learning, the nurse can implement outcome-based education plans. Identifying changes from baseline is important for monitoring interventions. Approval by the health care provider may not be necessary. Delegating the teaching activity to an unlicensed assistive personnel is inappropriate because it is not within the person's scope of practice.

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? Continue the education and remind the client that it is essential to learn self-care. Medicate the client for anxiety and continue the education later. Discontinue the education and attempt at another time. Discontinue the education and ask the client for permission to teach a family member.

Discontinue the education and attempt at another time. The nurse should always perform client education when the client is receptive of the education. The client verbalizes not being ready to learn, so education should be discontinued and continued at another time. Asking for permission to teach a family member does not encourage the client to learn self-care and acquire independence. The client does not need medication for anxiety at this time. This is a normal reaction. It would not be productive to continue the education because the client is not ready to learn.

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? Review with the client the risks and benefits of surgery. Ask the client to discuss the decision with family members. Discuss with the client the reasons for declining surgery. Notify the health care provider of the client's refusal.

Discuss with the client the reasons for declining surgery. 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.

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. Perform all care activities for the client to facilitate rest. Teach the family to anticipate the client's needs to care for the client. Arrange with the nurse case manager for an early discharge.

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

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. Determine the frequency of pain medication. Medicate the client with the ordered pain medication. Instruct the client in nonpharmacologic pain management.

Go to the client and assess the client's pain. 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.

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 Helping to allay a client's fears about surgery Administering medication to a client

Helping to allay a client's fears about surgery 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.

A nurse is caring for a postoperative client who reports a pain level of 6 on a scale from 1 to 10. After administering the prescribed pain medication, which intervention should the nurse include in the nursing care plan to monitor and evaluate pain? Assess nonpharmacologic modalities used to reduce pain. Implement the ABC guide of pain management. Ambulate the client after administration of pain medication. Review client goals for comfort.

Implement the ABC guide of pain management. Because administering a pain medication is implementing the plan of care, the next step would be to monitor and evaluate the client's pain level. By using the ABC guide to pain management in reassessing the client's pain, the nurse knows whether the current plan of care is safe and effective for the client, or if changes need to be made to meet the client's needs. Stating the use of pharmacologic and nonpharmacologic pain management modalities and ambulation and reviewing goals for comfort are all interventions to reduce pain, not methods for monitoring pain or evaluating the current plan.

The nurse is preparing a client to be discharged from the surgical unit following abdominal surgery. Which intervention will the nurse use to ensure the client's adherence to proper wound care techniques? Include family members or other caregivers in the education. Delegate teaching to unlicensed assistive personnel (UAP). Provide a video demonstration of abdominal wound care. Document client education prior to discharge from the unit.

Include family members or other caregivers in the education. The nurse will include family members or other caregivers in the education to ensure the client has adequate support upon discharge. It would not be appropriate to delegate client teaching to an unlicensed assistive personnel. The nurse should assess the client's learning needs, determine the client's preference, and provide the appropriate teaching method to promote effective teach-back of the skill; providing only a video may not suffice. Although client education must be documented prior to discharge, the nurse must first provide the education.

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? Perform vital signs and blood glucose level. 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. 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.

The emergency room (ER) has a strict protocol regarding intramuscular (IM) injection technique. A nurse working in the ER has learned of a new technique to decrease pain with IM injections from the nursing literature and would like to use it. What is the most appropriate way for the nurse to implement the technique? Begin using the technique to determine whether it is effective. Petition to change the protocol based on the new evidence. Ask the ER health care provider to order IM injections with the new technique. Research the protocols at other area emergency rooms.

Petition to change the protocol based on the new evidence. The nurse should petition to change the protocol on the basis of the new evidence. If the nurse believes that the change would be beneficial to clients, it is important to change the procedure for all clients. Therefore, having the ER health care provider write orders would not be the best choice because it would not affect all clients. Because the nurse must function under the protocols of the agency, it would be wrong to begin using the technique before the protocol is changed. Protocols at other area emergency rooms are not as authoritative as evidence from the nursing literature.

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? Inform the client that it is not necessary to wash hands before vital signs. Reassure the client that the nurse knows when to perform hand hygiene. Praise the client for taking an active role in the client's care. Tell the client that gloves are required for this procedure.

Praise the client for taking an active role in the client's care. 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.

What is the priority goal of interventions for a risk diagnosis? Reduce or eliminate contributing factors Prevent an actual problem Collect additional data Promote higher level wellness

Prevent an actual problem For "risk" nursing diagnoses, the priority goal is to prevent the problem from occurring by implementing interventions that reduce or eliminate risk factors or by collecting additional data. Promoting higher level wellness is a goal for "actual" nursing diagnoses.

Which nursing interventions are appropriate to perform when addressing a risk nursing diagnosis? Select all that apply. Prevent the problem. Reduce or eliminate risk factors. Monitor the client's status. Promote a higher level wellness. Collect additional data to rule out the diagnosis.

Prevent the problem. Reduce or eliminate risk factors. Monitor the client's status. Nursing interventions appropriate for risk nursing diagnoses include preventing the problem, reducing or eliminating risk factors, and monitoring the client's status. Promotion of higher level wellness addresses health promotion nursing diagnoses; collection of additional data to rule out the diagnosis would be necessary for possible nursing diagnoses.

Which action is a responsibility of the nurse in the nurse-nurse team relationship? Provide creative leadership to make the nursing unit a challenging place to work. Communicate nursing's perspective regarding the client and family. Challenge the client to develop self-care abilities that promote health. Intervene to promote healthy family functioning through education and advocacy.

Provide creative leadership to make the nursing unit a challenging place to work. In the nurse-nurse relationship, the nurse provides creative leadership to make the nursing unit a satisfying and challenging place to work. Challenging the client to develop self-care abilities that promote health is a role responsibility in the nurse-client relationship. Intervening to promote healthy family functioning is a role responsibility in the nurse-client-family relationship. Responsibilities of the nurse in the nurse-health care team relationship include communicating nursing's perspective regarding the client and family.

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 Developmental stage Research findings Current standards of care

Psychosocial background The nurse is demonstrating an awareness of the client's psychosocial background, which includes consideration of the client's socioeconomic status. Research findings and current standards of care are examples of nursing variables. Developmental stage is a client variable that addresses the developmental needs of a client.

In the implementation step of the nursing process, which activity is the nurse's first priority? Reassess client's needs. Document nursing care. Prioritize evaluation of care. Differentiate between subjective and objective data.

Reassess client's needs. 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.

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? Teach the content again utilizing the same method. Reassess the appropriateness of the method of instruction. Revise the plan to include the inclusion of a support group. Report the client's inability to learn to the case manager.

Reassess the appropriateness of the method of instruction. 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.

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. Notify the health care provider that the client has required pain medications. Perform additional nonpharmacological pain interventions.

Reassess the client to determine the effectiveness of the interventions. 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.

Before implementing any planned intervention, which action should the nurse take first? Have the required equipment ready for use. Reassess the client to determine whether the action is needed. 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. 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.

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 need for education. Assist the client to the bedside commode. Assess the client's risk for pressure injuries. Administer routine oral medications.

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

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. Continue assisting the client to the bathroom to ensure the client's safety. Consult with the physical therapist to determine the client's ability. 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. 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.

The registered nurse (RN) is delegating the task of assisting a postoperative client to the bathroom to the unlicensed assistive personnel (UAP). The nurse witnessed the UAP correctly perform the task on previous occasions and knows the UAP is competent to perform the task. The nurse has communicated how to get the client out and back into bed and told the UAP not to allow the client to bear weight on the left leg. The nurse validated that the activity was completed and gave the UAP feedback. Which delegation guideline did the nurse omit? Right task Right circumstance Right person Right supervision

Right circumstance The nurse fails to follow the delegation guideline related to right circumstance. The RN did not assess the client's needs or identify the outcome to be achieved by the task that was delegated. The other guidelines were followed.

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 Risk factors for and prevention of diabetes mellitus The severity of the client's disease The cellular metabolism of glucose

Risk factors for and prevention of diabetes mellitus 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 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 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? Educational Psychomotor Maintenance Surveillance

Surveillance 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.

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 client expresses a desire to learn how to manage the medication regime. The parents verbalize acceptance of the need to closely monitor their child's condition. The parents have comprehensive insurance coverage for their family's medical care.

The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years. 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 male. The client is married. The client is blind. The client is an architect. The client denies the need for education.

The client is blind. The client denies the need for education. 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.

The client has a diagnosis of Risk for Injury related to falls. How would the nurse know if the intervention was successful? The client calls for assistance to get out of bed. The client is free of falls. The client is taught safety precautions. The client verbalizes risks for injury.

The client is free of falls. Interventions for risk diagnoses are directed at prevention. The most appropriate way to evaluate the success of the interventions is to determine if the risk was prevented. The best evaluation criteria would be if the client remained free of falls. The client calling for assistance might prevent a fall, but does not signify that a fall will not occur. Teaching clients safety precautions and having the client verbalize risk for injuries is important but does not necessarily mean that an injury is prevented.

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 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. The nurse encourages clients to advocate for themselves instead of choosing a trusted family member or friend. 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. 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 nursing team, consisting of a nurse and experienced unlicensed assistive personnel (UAP), have worked well together for the past year. The nurse instructs the UAP to feed a stable stroke client, assist with dressing a client in preparation for discharge, and take vital signs of a third client in addition to notifying the nurse if the blood pressure becomes low. Which error has the nurse made? The nurse failed to communicate clear instructions regarding what constitutes a low blood pressure. The nurse delegated tasks to the UAP that are outside the scope of that person's preparation. The nurse failed to validate the UAP's knowledge and skill to perform the tasks. The nurse delegated too many tasks to the unlicensed assistive personnel.

The nurse failed to communicate clear instructions regarding what constitutes a low blood pressure. The nurse failed to communicate clear instructions to the UAP. The delegated tasks are not too numerous and are within the scope of a UAP's role and responsibilities. The nurse has had ample opportunity to validate the UAP's knowledge and skill to perform the tasks, as they have worked together for the past year.

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 unlicensed licensed personnel senior student in nursing school who is present for clinical licensed practical/vocational nurse

unlicensed licensed personnel 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.