Chapter 14

A nurse case manager is explaining the role of a case manager to a group of nursing students. One student asks if the case manager misses providing client care. What is the case manager's best response?

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

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 nurse is caring for a client admitted to the hospital for renal calculi. What is the action to take first?

Assess for bladder distention.

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.

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.

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.

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

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

Which nursing actions reflect the implementing step of 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

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 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 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

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 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 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.

The primary purpose of nursing implementation is to:

help the client achieve optimal levels of health.

Implementation of the plan of care is most successful when:

the nurse includes family members and other health care professionals.

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.

A nurse documents the diagnosis of Risk for Imbalanced Nutrition: More Than Body Requirements for a client who is hospitalized. What is the priority goal of interventions for a risk diagnosis?

Prevention of an actual problem

The nursing student is preparing to ambulate an obese client. The RN is concerned about the student's ability to safely ambulate the client. What would be the nurse's most appropriate action?

Tell the student that the RN will assist the student with the client's ambulation.