Nursing Process (PREPU Questions) CHP. 17 - IMPLEMENTING

Which parties are essential for the nurse to include in the implementation of a client's plan of care? Client, surgeon, and physician Client, physical therapist, and nursing staff Client, family, and physician Client, physician, and hospital director

Client, family, and physician

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 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 An older adult with pneumonia who is being discharged to the son's home tomorrow

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

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? "I asked my neighbors to help me with my yard work." "I sort my medication into an organizer every week." "My daughter has been staying with me the past few weeks." "My wife's been gone for about 7 months now."

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

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

Collaborate with other disciplines to revise the discharge plans.

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 ask the client for permission to teach a family member. 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 attempt at another time.

Which is the nurse's priority question to consider prior to delegating a task to an unlicensed assistive personnel (UAP)? How can I supervise the completion of this task? What is the client's condition? Does this task fall within the scope of a UAP? How can I explain the task to the UAP?

Does this task fall within the scope of a UAP?

The nurse is coordinating care for a client with continuous pulse oximetry who requires pharyngeal suctioning. To which staff member should the nurse avoid delegating the task of suctioning? Nursing assistant who is a nursing student Licensed practical nurse Registered nurse A senior nursing student present for clinical

Nursing assistant who is a nursing student

Which task would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? Provide the client with assistance in transferring to the bedside commode. Reassess the client's sacrum for redness when doing a bed bath. Secure the client's jewelry before surgery. Retrieve a unit of blood from the blood bank.

Provide the client with assistance in transferring to the bedside commode.

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? Reinforce the instructions for the treatment regimen to the client. Interview the family to determine if the client is giving accurate information. Report the findings to the physician for further plans. Inform the client that the blood pressure medication will have to be changed.

Report the findings to the physician for further plans.

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. Discuss the risks and benefits of a blood transfusion with the client. Discuss the client's refusal with hospital risk managers. Discuss the client's options with other church members.

Discuss possible alternatives to a blood transfusion with the physician.

Which statement best explains why continuing data collection is important? It enables the nurse to revise the care plan appropriately. It is the most efficient use of the nurse's time. It is difficult to collect complete data in the initial assessment. It meets current standards of care.

It enables the nurse to revise the care plan appropriately.

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. Determine whether the nurses have time to give the client's bath at night. Tell the client that the physician has ordered sleep medication if necessary. Ask the client for permission to give the bath in the morning.

Reschedule the client's bath to the evening shift.

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

help the client achieve optimal levels of health.

Which statement by a nurse case manager regarding this nurse's role in client care is most accurate? "Even though I do not provide care to clients, my work is very important." "Moving away from client care is a necessary step to advancing my career." "I provide a critical service that is necessary for financial reimbursement." "I provide indirect care to my clients by coordinating their treatment with other disciplines."

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

The client tells the nurse, "I think the nurse last night may have given me the wrong medication, but I was afraid to say anything." What is the nurse's most appropriate response? "You should always speak up if you have any questions about your care." "You always have the right to refuse any medication or treatment." "I will discuss your concerns with the night nurse." "I will report your concerns to the nurse manager."

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

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 mostappropriate action? Ask the client to verbalize the medication regimen and diet modifications required. Ask the gastroenterologist to explain the treatment plan to the client and family again. Ask the 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.

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? Tell the client to report any side effects experienced. Assess the client's blood pressure to determine if the medication is indicated. Ask the client to verbalize the purpose of the medication. Determine the client's reaction to the medication in the past.

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

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? Determine the frequency of pain medication. Instruct the client in nonpharmacologic pain management. Medicate the client with the ordered pain medication. Go to the client and assess the client's pain.

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

The physician has ordered that the client should ambulate 3 times a day. The nurse enters the room to ambulate the client and the client reports pain. What is the nurse's most appropriate action? Ambulate the client and medicate later. Explain to the client the benefits of ambulation. Medicate the client and wait to ambulate later. Emphasize to the client the importance of following the treatment plan.

Medicate the client and wait to ambulate later.

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? Notify the physician that the client has required pain medications. Reassess the client to determine the effectiveness of the interventions. Instruct the client that pain medication is available at regular intervals. Perform additional nonpharmacological pain interventions.

Reassess the client to determine the effectiveness of the interventions.