implementation ch 14 coursepoint

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

"We ask your name to ensure that we are treating the right client." The primary reason for asking the client to state her name is to ensure that the nurse is dealing with the correct client. Asking the client to state her 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 her 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 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 physician 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 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 his 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 says that she will not make a decision without her husband's consent. What is the nurse's best course of action?

Ask the surgeon to wait until the client has had a chance to talk to her husband. 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 her husband. Telling the client that she is responsible for her health care decisions does not respect the client's desire to consult her husband. The client has not indicated that she is fearful of her husband. Informing the surgeon that the nurse will not sign the consent form will not satisfy the client's request.

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 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 physician may not be necessary. Delegating the teaching activity to an unlicensed assistive personnel (UAP) is inappropriate because it is not in accordance with her capabilities.

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

Discuss with the client the reasons for declining surgery. The nurse 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 physician until the assessment is complete.

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. 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.

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

Helping to allay a client's fears about surgery An independent (nurse-initiated) action is one that is not dependent on the physician. Helping the client decrease his or her fear about surgery by answering questions or arranging a meeting with the surgeon is an independent nursing intervention. Executing physician's orders, such as catheterization and medication administration, are examples of dependent nursing interventions. Meeting with other health care professionals describes collaborative care.

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

It enables the nurse to revise the care plan appropriately. Continuous data collection ensures that the nurse has the most current client data to evaluate, which allows for updating the care plan as needed. A complete assessment is performed upon admission, but the client's condition is always changing. The purpose of continued data collection is to provide good client care; it does not relate directly to efficiency of nursing care. While continuous data collection meets standards of care, it is not the primary reason for ongoing assessments.

The nurse 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. This question asks specifically about evaluation. Modeling self-care behaviors is an intervention, not an evaluation or assessment technique. When considering the responses, first check for sentence structure. Only one of the choices contains the three elements of the nursing diagnosis: the diagnostic label, the related factors, and the defining characteristics. The question asks for an actual diagnosis; this eliminates any risk, wellness, or potential diagnoses.

The nurse is assigned a client who had an uneventful colon resection 2 days ago and requires a dressing change. To which nursing team member should the nurse avoid delegating the dressing change?

Nursing assistant The nurse should avoid delegating the dressing change to the nursing assistant. The dressing change would be within the scope of practice of the registered nurse, licensed practical nurse, and the senior nursing student.

The nurse is caring for Mr. M., a 48-year-old man with congestive heart failure. The nurse manager informs the nurse that Mr. M. was enrolled in a clinical trial to assess whether a 10-minute walk, 3 times per day, leads to expedited discharge. Which type of evaluation best describes what the researchers are examining?

Outcome evaluation An outcome evaluation determines the extent to which a client's behavioral response to a nursing intervention reflects the outcome criteria.

The nurse is to delegate certain tasks to unlicensed assistive personnel (UAP). Which of the following tasks can be appropriately assigned to a UAP?

Provide client assistance to the bedside commode. Assisting with toileting is one of the tasks permitted by the state board of nursing for UAP. This task is commonly performed by UAP in health facilities.

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. Before any intervention is implemented, the nurse should assess if the intervention is still indicated. Since the client has reported voiding, the nurse should take measures to see if the client is still retaining urine. The nurse cannot tell the client the catheter is necessary until after the assessment is complete. The nurse should wait until the assessment is complete before deciding whether the catheter is indicated.

A nurse in the ICU (intensive care unit) has been assigned to care for a client who was seriously injured during a gang rape. The nurse was raped 6 months ago and feels that she will be too upset to care for the client properly. How should the nurse deal with the assignment?

Recognize her 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 her 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.

The nurse is preparing to give the client a bath early in the morning. The client states, "I prefer to take my bath at night. It helps me sleep." What is the nurse's most appropriate action?

Reschedule the client's bath to the evening shift. The client's preferences are a primary consideration in scheduling interventions. The client's preference to have a bath at night requires a change in scheduling. Asking for permission to give the bath in the morning does not address the client's preference. The schedule of the nurses should not take priority over client needs. Informing the client about sleep medication does not address the client's preference.

The nurse is working with Ms. V. today. Ms. V. is having a difficult time accepting her new diagnosis of type 2 diabetes. Thenurse pulls up a chair next to Ms. V.'s bed and holds her hand while listening to her story. What type of nursing intervention is the nurse engaging in?

Supportive intervention Supportive interventions emphasize use of communication skills, relief of spiritual distress, and caring behaviors. Psychosocial interventions focus on resolving emotional, psychological, or social problems. 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.

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 Surveillance nursing interventions include detecting changes from baseline data and recognizing abnormal responses.

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 discusses the specifics of what was taught during the session. The client verbalizes understanding of the instructions. The client is able to answer the nurse's questions. After an intervention is implemented, the nurse must assess the effectiveness of the intervention. The client stating an understanding of the instructions gives the nurse an indication that learning has taken place. Asking the client questions and receiving the correct answers is an excellent way to judge the client's knowledge. The client asking for the nurse to repeat the instructions shows that the client does not have a clear understanding. The client's statement that his wife will handle his care signals that the client is not ready to learn at this time. The client's ability to discuss the specifics of the material suggests that learning has taken place.

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

The client 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.

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 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 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 According to the ABC priority framework, the client who should be assessed first is the asthma client with shortness of breath and a respiratory rate of 26 bpm. The appendectomy client with an elevated temperature should be assessed for suspected infection. However, this is not the priority action. The diabetic client should receive education regarding administration of insulin but this is not a priority. The hysterectomy client should be assessed for possible hemorrhage. However, according to the ABC priority framework, this is not the priority.

Which nursing action can be categorized as a surveillance or monitoring intervention?

auscultating of bilateral lung sounds Surveillance or monitoring nursing interventions includes detecting changes from baseline data and recognizing abnormal responses. Nurses rely on the senses to detect changes: observing the appearance and characteristics of clients; hearing by auscultation, pitch, and tone; detecting odors and comparing them with past experience and knowledge of specific problems; and using touch to assess body temperature, skin condition, clamminess, or diaphoresis. Nurses use all of these surveillance or monitoring activities to determine the current status of clients and changes from previous states. Nurses often detect subtle changes in a client's condition and communicate them to the physician to minimize problems.

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

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

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." 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.

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." The nurse cannot care for client without first ensuring self-care. The nurse is tired and most appropriately is declining to work because the nurse will not be able to function at full capacity. Simply stating that the nurse wants a day off does not fully address the situation. The option of working tomorrow is not appropriate because the nurse needs to rest after working a night shift.

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

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

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 The nurse should avoid delegating this client to the nursing assistant who is a nursing student. Suctioning and the associated evaluation of the client would be within the scope of practice of the registered nurse, licensed practical nurse, and the senior nursing student present for clinical.

The nurse caring for a client who is recovering after a motor vehicle accident is planning for the client to begin increasing responsibility for self-care. What would be the nurse's most appropriate strategy?

The nurse encourages the client to take a shower instead of receiving a bed bath. It is important for the nurse to encourage the client to achieve independence in self-care. The nurse would best accomplish this by encouraging the client to gradually do more for himself. There is no evidence that the client's recovery is progressing too slowly. There is no indication that an early discharge would be beneficial for the client. There is also no indication that the family is doing too much for the client. The client is not fully capable of self-care and will still need the assistance of family.

The primary purpose of nursing implementation is to:

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.

Implementation of the plan of care is most successful when:

the nurse includes family members and other health care professionals. Family members and support people, as well as other health care professionals, may be involved in the implementation of the plan of care. The plan of care is best implemented when clients who are able and willing to participate have the maximum opportunity to provide self-care. Clients and their support systems should be involved in decision making. The nurse will continue to collect data and modify the plan of care during the implementation phase. All activities should be documented during the implementation phase.

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. 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 was given.

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 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.

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 Surveillance interventions include detecting changes from baseline data and recognizing abnormal response. Nurses rely on the senses to detect changes: observing the appearance and characteristics of clients; hearing by auscultation, pitch, and tone. Nurses use these surveillance activities to determine the current status of clients and changes from previous states.

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

ensuring that the endotracheal tube is secure ABCs (Airway, Breathing and Circulation) are always top priority in client care. In this example, ensuring that the client maintains a patent airway will always be top priority. Each of these nursing tasks is important and will need to be accomplished at some point during client care.

A client with diabetes who has been closely following the prescribed plan of care for over a year is being seen at an outpatient setting. 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 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 that the care regimen has not been followed.

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

"My wife's been gone for about 7 months now." The client's loss may be affecting how he is able to provide self-care. Emotionally, he may be depressed and questioning the benefits of his health care regimen, or he may have depended on his wife to help with his health care and not have the ability to take care of himself. Assessment of the client allows the nurse to alter the plan of care to meet his needs. The statements concerning having a family member staying with him, having help with the yard work, and sorting medications into an organizer should be explored, but do not reflect the same emotional impact on the client's life as the loss of a spouse.

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. Urinary retention could occur if a kidney stone has become lodged in the urethra. Forcing fluids, straining the urine after each void, and diet as tolerated are appropriate interventions, but these do not address the safety issue of first assessing the bladder for distension; this could potentially cause the client discomfort and harm.

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

Assist the client to the bedside commode. Record the client's intake and output. It is crucial for the nurse to be aware of the legalities of delegation to unlicensed assistive personnel. 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 ulcers fall only under the nurse's scope of practice. Administering oral medications is not appropriate for unlicensed assistive personnel.

Delegating responsibilities is one of the tools the nurse uses during client care. Which statement is appropriate when delegating?

Delegate tasks that involve minimal risk. Provide appropriate supervision when delegating tasks. Delegate tasks that follow the individual's scope of practice. Provide feedback after task is completed. Delegation - The transfer of responsibility for the performance of a task to another staff while retaining accountability for the outcome. A licensed RN will delegate tasks to unlicensed assistive personnel (UAP). 1. Right Person - The task is within the scope of the UAPs duties. - The individual has been trained and has the skill to perform the task. - The individual is willing to accept the responsibility for performing the task. 2. Right Task - The task permitted by the state board of nursing and the institution's policies. - The task is commonly performed by UAP. - The task is performed according to an established sequence of steps. - The task involves little or no modification from one client to another. - The task involves minimal risk. - The task does not involve assessment or clinical judgment. - The nursing process, including assessment, may not be delegated. - Client education cannot be delegated to UAP. 3. Right Circumstance - Assess client to be sure condition remains stable and delegation is appropriate. - Match complexity of the activity with the competency level of the UAP. - Be sure appropriate supervision is possible. 4. Right Communication - Identify tasks and expectations for client assignment. - Provide clear report, including unique client requirements and expected observations to report and record. - Assess UAP understanding of expectations, welcome questions, and provide clarification if needed. 5. Right Evaluation - Check in with UAP to assess need for additional supervision or a revision in the plan. - Assess if the delegated task was performed correctly and documented. - Ask if the UAP has any information about the client that the client would like to share. - Provide feedback to UAP regarding what was done well and if there are areas for improvement.

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. As coordinator of the client's care, the nurse functions as an intermediary between the physician and the client. In order to honor the client's wishes, the nurse would most appropriately consult with the physician to meet the client's physical needs, as well as the client's spiritual needs. The risk and benefits of a blood transfusion are not the relevant issue with the client. Discussing the client's options with other church members would violate the client's privacy and would not meet the client's physical needs. It might be advisable to discuss the client's refusal of care with the hospital risk manager to protect the legal requirements of the institution, but it is not the priority.

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. 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.

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 Each of these factors contributes to the prioritization of nursing diagnoses except the client's finances. The nursing code of ethics states that clients receive the same treatment regardless of their ability to pay.

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 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. The assessment phase would include the nurse assessing the client prior to giving the medication to ensure that it is an appropriate action. The planning step is when a plan of care is developed for this client. Evaluation should occur after medication administration to evaluate the outcome of the action.

The nurse is preparing a client with a bowel obstruction for emergency surgery. Of the following interventions, which has the highest priority?

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, instruction in wound care, and dietary restrictions are important, but not necessary before the surgery.

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. It is appropriate for health care professionals to be constantly evaluating whether the client's needs are being met in the best way. The experienced nurse should listen to the ideas of the new nurse and decide if the approach would be beneficial to the client. If the nurse's initial reaction is to quote policy and procedure, it does not allow for the exchange of ideas with the new nurse. It would not be necessary to consult with another experienced nurse or with the client's physician.

When the nurse enters the room to assess a client's vital signs, the client insists that the nurse perform handwashing. What is the nurse's most appropriate action?

Praise the client for taking an active role in his care. 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.

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 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.

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. After implementing any interventions (such as pain medication) or any nonpharmacologic pain control method (such as splinting the incision) the nurse must always reassess the client to determine the effectiveness of the interventions. If the interventions are ineffective, the plan is revised and additional interventions are planned.

A client with hypertension being seen for follow-up care has a blood pressure of 160/100. 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 physician for further plans. The nurse should report the findings to the physician 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 physician's decision.

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

Risk factors and prevention of diabetes mellitus An important nursing function is to enable clients to prevent illness. Since 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 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: HR 74, RR 8, BP 114/68. After reviewing the nursing care plan and physician orders, the nurse administers naloxone. What would allow the nurse to initiate this action?

Standing orders Standing orders allow the nurse to initiate actions that ordinarily require the order of a physician, 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.

Nurse Sanchez is a community health nurse in a largely Hispanic community. She has noticed that a large percentage of her clients with type 2 diabetes struggle to find food choices that are a compatible with the cooking style of their culture. Nurse Sanchez decides to organize a cooking class to demonstrate to clients with type 2 diabetes how to prepare culturally appropriate foods. Nurse Sanchez's actions could be labeled as what types of nursing interventions? Select all that apply.

Supervisory intervention Psychosocial intervention Educational intervention Nurse Sanchez is exhibiting educational intervention as she is demonstrating to her clients how to prepare appropriate foods; She is also exhibiting psychosocial intervention in that she is focusing on resolving her clients cultural and social views on preparing foods that may not be healthy. Nurse In addition, Nurse Sanchez is exhibiting supervisory intervention in that she is overseeing and encouraging client changes regarding diet.

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. 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 client has a diagnosis of Risk for Injury related to falls. How would the nurse know if the intervention was successful?

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 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. When reassessing the client after implementing interventions to increase oxygenation, the nurse would look for a decrease in respiratory rate to 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.

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. The nurse should recognize that she 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.

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 physician is termed:

standing orders. Standing orders empower the nurse to initiate actions that ordinarily require the order or supervision of a physician, 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.

An unlicensed assistive personnel (UAP) has worked on the postpartum unit for many years. The UAP has been oriented well and provides excellent client care. What duties could the professional nurse appropriately delegate to the UAP? Select all that apply.

transporting the infant to the mother's room according to hospital policy assisting the client with personal hygiene needs and ambulation It is essential when delegating duties that the RN is aware her 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.