Ch. 17 Implementing
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?
"My wife's been gone for about 7 months now."
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.
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.
Which nursing action can be categorized as a surveillance or monitoring intervention?
Auscultating of bilateral lung sounds
Which parties are essential for the nurse to include in the implementation of a client's plan of care?
Client, family, and physician
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 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 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.
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.
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.
Which is the priority question for the nurse to consider before implementing a new intervention?
Does this treatment make sense for this client?
The nurse has administered pain medication to a client with a fractured femur. One hour later, the client reports relief of pain. What parameters would the nurse document to support evaluation of pain management?
Effectiveness of intervention including current pain scale, time frame, and client self-report.
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.
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
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.
Which is an independent (nurse-initiated) action?
Helping to allay a client's fears about surgery
A student nurse has reported for a clinical preceptorship in a hospital and has been reassigned from the medical surgical unit to a pediatric unit. The student nurse has never worked with pediatric clients. Which of the following actions should the student nurse take in this situation?
Inform the supervisor that she cannot accept this assignment because of a lack of experience with pediatric clients.
Which statement best explains why continuing data collection is important?
It enables the nurse to revise the care plan appropriately.
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?
Medicate the client and wait to ambulate later.
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 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 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 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.
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.
The nurse is discussing diabetes mellitus with the family members of a client recently diagnosed. To promote the health of the family members, what would be the most important information for the nurse to include?
Risk factors for and prevention of diabetes mellitus
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
A new unlicensed assistive personnel (UAP) is preparing to ambulate an obese client. The registered nurse (RN) is concerned about the UAP's ability to safely ambulate the client. Which would be the nurse's most appropriate action?
Tell the UAP that the RN will assist the UAP with the client's ambulation.
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.
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.
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 is able to answer the nurse's questions. The client discusses the specifics of what was taught during the session.
The Joint Commission (TJC) encourages clients to become active, involved, and informed participants on the health care team. What nursing action follows TJC recommendations for improving client safety by encouraging them to speak up?
The nurse encourages the client to participate in all treatment decisions as the center of the health care team.
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.
What are the goals of the research that is behind the Nursing Outcomes Classification (NOC) system? Select all that apply.
To identify, label, and validate nursing-sensitive client outcomes and indicators To evaluate the validity and usefulness of the classification in clinical field testing To define and test measurement procedures for the outcomes and indicators
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
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.
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 the client's care.
The nurse in a burn intensive care unit (BICU) is caring for a 3-year-old child who was burned with scalding hot water. The client has burns covering 75% of the body. The client's condition is critical but stable. At 1000, the nurse reassesses the client and finds that the client is agitated and pulling at the endotracheal tube. Which is the nurse's priority intervention for this client at this time?
Ensuring that the endotracheal tube is secure
The nurse ascertains that a client is failing to follow the plan of care that was collaboratively developed. Further investigation determines that the plan of care is not appropriate for this client. What is the nurse's next step in correcting this problem?
Make changes in the plan of care based upon assessment data.