Fundamentals Nursing Prep U Chapter 14 Implementing

A nurse suspects that the client with Crohn's disease does not understand the medication regimen or diet modifications required to manage the illness. What is the nurse's most appropriate action?

Ask the client to verbalize the medication regimen and diet modifications required.

The nurse is caring for a client admitted to the hospital for renal calculi. What is the action to take first?

Assess for bladder distention.

The nursing is caring for several clients. Which client can the nurse delegate to the unlicensed assistive personnel?

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

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

Determine the client's willingness to follow the regimen.

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.

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. Which has the nurse failed to organize?

Equipment and personnel

The nurse is assigned a client who had an uneventful colon resection two days ago and requires a dressing change. To which nursing team member should the nurse avoid delegating the dressing change?

Nursing assistant

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

Nursing assistant who is a nursing student

Nurse Mayweather is auscultating lung sounds. She notes crackles in the LLL which were not present at the start of the shift. Nurse Mayweather is engaged in which type of nursing intervention?

Surveillance intervention

The client reports right knee pain of 6/10 on the pain scale and requests for medication. The nurse assesses and flushes the IV site. Which type of intervention skill is the nurse using?

Technical skill

The registered nurse is working with an unlicensed assistive personnel. Which client should the nurse not delegate to the unlicensed assistive personnel?

The client with continuous pulse oximetry who requires pharyngeal suctioning.

The nurse is planning instruction on wound care to an adult client. What variables would cause the nurse to alter the education plan? Select all that apply.

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

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

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

The nurse is currently completing the last of three consecutive night shifts. The unit will be short-staffed on day shift and the charge nurse wants the nurse to work this as an overtime shift. What is the nurse's most appropriate response?

"I will not work tomorrow because I would be a danger to my clients."

When the nurse is administering medication, an older adult client states, "Why does everyone keep asking my name? I've been here for days." How should the nurse respond to the client?

"We ask your name to ensure that we are treating the right client."

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.

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

Finances of the client

A client cannot afford the treatment prescribed. Who would be the most appropriate professional for the nurse to involve with the client's care?

Nurse case manager

The emergency room has a strict protocol regarding IM (intramuscular) injection technique. A nurse working in the emergency room has learned of a new technique to decrease pain with IM injections and would like to use it. What is the most appropriate way for the nurse to implement the technique?

Petition to change the protocol based on the new evidence.

The nurse has assessed a client and determined that the client has abnormal breath sounds and low oxygen saturation level. The nurse is performing what type of nursing intervention?

Surveillance

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

bed bath for the newly-admitted client who has multiple skin lesions

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

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

What assessment data would indicate to the nurse at the conclusion of an education session that the client education was effective? Mark all that apply.

• The client verbalizes understanding of the instructions. • The client is able to answer the nurse's questions. • The client discusses the specifics of what was taught during the session.

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

Communicate with the physician for additional orders.

A client tells the nurse, "My doctor has told me I have to have a blood transfusion, but I am a Jehovah's Witness and I can't take one." What is the nurse's most appropriate intervention?

Discuss possible alternatives to a blood transfusion with the physician.

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

Discuss with the client the reasons for declining surgery.

A nurse is administering metformin to a client who has a new onset of diabetes mellitus type 2. Which of the following steps of nursing process is the nurse using?

Implementation

The RN is orienting a new nurse who suggests a different way to perform a procedure. What is the RN's most appropriate reaction?

Listen to the new nurse's suggestion and evaluate its usefulness.

Nursing interventions for the client after prostate surgery include assisting the client to ambulate to the bathroom. The nurse concludes that the client no longer requires assistance. What is the nurse's best action?

Revise the care plan to allow the client to ambulate to the bathroom independently.

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

Risk factors and prevention of diabetes mellitus

A nurse who is experienced caring only for well babies is assigned to the newborn intensive care nursery (NICU) because of a shortage of nurses in the NICU. The nurse is assigned to an infant on a ventilator who will require blood transfusions during the shift. What is the nurse's most appropriate course of action?

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

A nursing student received a report on his assigned clients for the clinical day. Which client should the student nurse plan to assess first?

an asthma client who reports shortness of breath with a respiratory rate of 26 bpm

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 helps a client in hospice fill out a living will form.

A registered nurse (RN) and a licensed practical nurse (LPN) are caring for a client who has been admitted with an acute exacerbation of chronic obstructive pulmonary disease (COPD). Which nursing actions can the RN delegate to the LPN? Select all that apply.

• Obtaining pulse oximetry • Auscultating breath sounds • Administering an oral antibiotic

The client is about to have blood drawn before seeing the health care provider. The spouse while smiling and holding the client's hand, states "Here comes the blood sucker. It is going to hurt bad." This statement is an example of which type of intervention? Select all that apply.

• Psychosocial • Supportive

One hour after receiving blood pressure medication, the client reports feeling lightheaded and dizzy. What is the nurse's first action?

Assess the client's blood pressure.

The nurse has prepared to educate a client about caring for a new colostomy. When the nurse begins the instruction, the client states, "I am not ready to deal with this now. I am feeling overwhelmed." What is the nurse's most appropriate action?

Discontinue the education and attempt at another time.

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

Model self-care behaviors for the client.

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. What is the nurse's most appropriate action?

Reassess if the urinary catheter is still necessary for the client.

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.