Prep U ch. 17

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 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.

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

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

A client requires a change and reapplication of a colostomy bag. The nurse has never changed an ostomy bag before. What is the nurse's best course of action?

ask a skilled nurse to assist with the procedure

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?

ask the surgeon to wait until the client has had a chance to talk to the spouse

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

Which are activities the nurse typically performs during the implementation step of the nursing process? Select all that apply.

collecting additional client data modifying the client plan of care

A charge nurse has assigned a new nurse a task that the nurse has not been trained to perform. Which is the most appropriate action for the nurse to take?

consult with the charge nurse before performing the procedure

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 instruction until the visitors leave

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

determine the clients willingness to follow the regimen

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

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

finances of the client

The nurse is preparing a client with a bowel obstruction for emergency surgery. Which intervention has the highest priority for this client?

inform the client what to expect after surgery

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

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?

outcome

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?

petition to change the protocol based on the new evidence

Which task would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)?

providing the client assistance in transferring to the bedside commode

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?

reassess the appropriateness of the method of instruction

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

While auscultating a client's lung sounds, the nurse notes crackles in the left lower lobe, which were not present at the start of the shift. The nurse is engaged in which type of nursing intervention?

surveillance

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 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?

client with a high fever receiving IV fluids, antibiotics, and oxygen

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

communicate with physicians for additional orders

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 physicians wrote orders to ambulate the client, whereas another physician ordered strict bed rest for the client. How would the nurse most appropriately remedy this conflict?

communicate with the physicians to coordinate their orders

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 clients pain

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 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

A client is admitted to the mental health center after attempting suicide. Which client concern is the priority for the nurse to manage?

risk of self harm

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

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

Which is an independent (nurse-initiated) action?

Helping to allay a client's fears about surgery

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.

Which nursing actions reflect the implementing step of the nursing process? Select all that apply.

Providing health education to reduce health risks Referring the client to community resources, when necessary Using evidence-based interventions individualized for the client

Which parties are essential for the nurse to include in the implementation of a client's plan of care?

client family and physician

Which is the priority question for the nurse to consider before implementing a new intervention?

does this treatment make sense for the client

Which action is a nursing intervention that facilitates lifespan care?

educate family members about normal growth and development patterns

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 alone

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