PrepU: Ch.14 Implementing

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

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

In order to successfully implement the plan of care, what parties are essential for the nurse to include?

*Client, Family, and Physician*

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.* -Teach the content again utilizing the same method. -Revise the plan to include the inclusion of a support group. 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.

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."* - "I will discuss your concerns with the night nurse." -"You always have the right to refuse any medication or treatment." - "I will report your concerns to the nurse manager." The priority is to empower the client into taking an active role in his 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.

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* -Feedback from the family -The client's condition -Time and resources 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.

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?

-LPN -Registered nurse -*Nursing assistant* -A senior nursing student present for clinical 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 but not the nursing assistant.

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.* -Assist the client to reposition and splint the incision. -Consult with the physician for additional pain medication. -Discuss the frequency of pain medication administration with the client.

The mother of a pediatric client being discharged confides to the nurse that her husband is abusive and she is afraid to return home. What is the nurse's most appropriate action?

-* Coordinate with the case manager to make a safe discharge plan.* -Give the mother telephone numbers of women's shelters. -Advise the mother that she should report her concerns to the police. The nurse's top priority is the safety of the client. The person most qualified to consider the options available to protect the mother and client is the case manager. It is not sufficient to simply give the mother telephone numbers of women's shelters. This does not take into account the possible needs of the child after discharge. Advising the mother that she should report concerns to the police does not address the discharge needs of the client. Arranging a counseling session does not meet the immediate discharge needs of the client.

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

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

-*Helping to allay a patient's fears about surgery* -Meeting with other health care professionals to discuss a patient -Administering medication to a patient -Executing physician orders for a catheter An independent (nurse-initiated) action is one that is not dependent on the physician. Helping the patient with decreasing their 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.

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.* -Inform the client that the catheter will no longer be necessary. -Instruct the client that the catheter is essential to check for urinary retention. -Insert the urinary catheter as ordered to relieve the urinary retention.

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.* -Notify the physician that the client has required pain medications. -Instruct the client that pain medication is available at regular intervals. -Perform additional non-pharmacologic pain interventions.

The registered nurse (RN) is delegating the task of assisting a post-operative 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 was omitted by the nurse?

-*right circumstance* -right supervision -right task -right person Right circumstance is not one of the five guidelines noted in the scenario. 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. P314