Chapter 14: PREPU

Question 24

In the implementation step of the nursing process, a nurse is to utilize certain activities to be effective in the care of a client. Which activity is the priority? ANSWER: Reassess client's needs.

Question 32

Nurses implement care for clients in various health care settings. Which activities would typically be carried out during the implementation step of the nursing process? Select all that apply. ANSWER: >Collecting additional client data >Modifying the client plan of care (During the implementation phase the nurse carries out the plan of care, continues data collection, modifies the plan of care as needed, and documents the care provided. )

Question 23

Nurses use the Nursing Outcomes Classification when choosing nursing goals for clients. What are the goals of the research that is behind the Nursing Outcomes Classification (NOC)? Select all that apply. ANSWER: >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 (The goals of research behind the NOC is to identify, label, validate, and classify nursing-sensitive client outcomes and indicators; evaluate the validity and usefulness of the classification in clinical field testing; and define and test measurement procedures for the outcomes and indicators. )

Question 2

Nurses utilize the McCloskey, Dochterman, and Bulechek Nursing Interventions Classification (NIC) report of research when choosing nursing interventions for clients. What are advantages of having standard Nursing Interventions Classifications (NIC)? Select all that apply. ANSWER: >Teaching decision making >Allocating nursing resources >Developing information systems >Communicating nursing to non-nurses

Question 10

The RN is orienting a new nurse who suggests a different way to perform a procedure. What is the RN's most appropriate reaction? ANSWER: Listen to the new nurse's suggestion and evaluate its usefulness.

Question 13

The client has a diagnosis of Risk for Injury related to falls. How would the nurse know if the intervention was successful? ANSWER: The client is free of falls

Question 30

The client is about to have blood drawn before seeing the health care provider. The spouse while smiling and holding the client's hand, states "Here comes the blood sucker. It is going to hurt bad." This statement is an example of which type of intervention? Select all that apply. ANSWER: >Psychosocial >Supportive >Physical

Question 29

The client reports right knee pain of 6/10 on the pain scale and requests for medication. The nurse assesses and flushes the IV site. Which type of intervention skill is the nurse using? ANSWER: Technical skills (Technical skills are used to carry out treatments and procedures. Nurses learn the specific skills through clinical practice. Technical competence means being able to use equipment, machines, and supplies in a particular specialty.)

Question 9

The emergency room has a strict protocol regarding IM (intramuscular) injection technique. A nurse working in the emergency room has learned of a new technique to decrease pain with IM injections and would like to use it. What is the most appropriate way for the nurse to implement the technique? ANSWER: Petition to change the protocol based on the new evidence. (The nurse should petition to change the protocol on the basis of the new evidence. If the nurse feels that the change would be beneficial to clients)

Question 11

The nurse is attending a conference on evidence-based practice. Which statement by the nurse indicates further education is needed? ANSWER: "I must conduct research to validate the usefulness of my nursing interventions." (Nurses can learn about evidence-based practice by reading professional nursing journals, attending nursing workshops, and consulting evidence-based practice resources, such as the Agency for Healthcare Research and Quality.)

Question 7

The nurse is caring for a client admitted to the hospital for renal calculi. What is the action to take first? ANSWER: Assess for bladder distention.

Question 19

The nurse is caring for a client who does not speak the same language. The unlicensed assistive personnel (UAP) speaks the same language as the client. What parts of communicating with the client could the nurse appropriately delegate to the UAP? Select all that apply. ANSWER: >Ask the client questions regarding personal care needs. >Orient the client and family to the room, including the call light button.

Question 8

The nurse is caring for a postoperative client who is receiving morphine sulfate for pain management. The nurse obtains the following vital signs: HR 74, RR 8, BP 114/68. After reviewing the nursing care plan and physician orders, the nurse administers naloxone. What would allow the nurse to initiate this action? ANSWER: Standing orders (Standing orders allow the nurse to initiate actions that ordinarily require the order of a physician, such as administering naloxone. An algorithm is a binary decision tree that guides stepwise assessment and intervention for a high-risk subgroup of clients. A protocol is a written plan that details nursing activities to be executed in specific situations. An order set is a preprinted set of provider orders that expedite the provider order process.)

Question 25

The nurse is discussing dietary options with a client who is upset due to the inability of not being able to have foods previously enjoyed. The nurse states "You may not be able to have steak but you can have grilled salmon or grilled chicken. Which do you prefer?" What is the purpose for giving the client an option? ANSWER: Giving the client options demonstrates active participation in care

Question 3

The nursing is caring for several clients. Which intervention can the nurse direct the unlicensed assistive personnel (UAP) to perform? ANSWER: Bathe a client with stable angina who has a continuous IV infusing.

Question 5

The nursing team, consisting of a nurse and experienced unlicensed assistive personnel, have worked well together for the past year. One of the nurse's assigned clients is injured in a fall and requires uninterrupted attention. The nurse instructs the UAP to feed a stable stroke client, assist with dressing a client in preparation for discharge, and take vital signs of a third client in addition to notifying the nurse if the blood pressure becomes low. Which error has the nurse made? ANSWER: The nurse failed to communicate clear instructions regarding what constitutes a low blood pressure.

Question 31

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? ANSWER: right circumstance

Question 28

Which action is a responsibility of the nurse in the nurse-nurse team relationship? ANSWER: Provide creative leadership to make the nursing unit a challenging place to work. (In the nurse-nurse relationship, the nurse provides creative leadership to make the nursing unit a satisfying and challenging place to work. Challenging the client to develop self-care abilities that promote health is a role responsibility in the nurse-client relationship. Intervening to promote healthy family functioning is a role responsibility in the nurse-client-family relationship. Responsibilities of the nurse in the nurse-health care team relationship include communicating nursing's perspective regarding the client and family.)

Question 15

Which examples are essential components for delegating nursing care? Select all that apply. ANSWER: >The task is delegated to a person with sufficient knowledge and skill for completing the task. >Instructions have been clearly communicated by the nurse to the unlicensed assistive personnel (UAP). >The unlicensed assistive personnel can verbalize what information is to be reported to the nurse

Question 27

Which nursing actions reflect the implementing step of nursing process? (Select all that apply.) ANSWER: >Providing health education to reduce health risks >Referring the client to community resources, when necessary >Using evidence-based interventions individualized for the client

Question 16

Which nursing intervention is appropriate for a risk nursing diagnosis? Select all that apply. ANSWER: >Prevent the problem. >Reduce or eliminate risk factors. >Monitor the client's status. (Promotion of higher level wellness addresses actual nursing diagnoses; collection of additional data to rule out the diagnosis would be necessary for possible nursing diagnoses.)

Question 26

Which nursing intervention is most likely to be allowed within the parameters of a protocol or standing order? ANSWER: Administering a glycerin suppository to a constipated client who has not responded to oral stool softeners (Standing orders and protocols often surround the management of bowel elimination. Modification of a client's IV fluid or administration of a new antihypertensive are client-specific interventions that are physician initiated. The care team cannot independently change a client's advance directive.)

Question 22

A client being treated for myasthenia gravis at home tells the nurse, "This medicine is so expensive. I have only been taking half of what the doctor ordered." How would the nurse most effectively meet this client's need? ANSWER: Collaborate with other disciplines to determine the best way to meet the client's medication requirements.

Question 12

A client has a nursing diagnosis of Possible Spiritual Distress. What is the most appropriate nursing intervention? ANSWER: Discuss spirituality with the client. (The only way to determine if the client is in spiritual distress is by discussing it with the client. The client's pastor does not know how the client feels. It would be inappropriate to offer to pray with the client if the client does not desire this. Leaving the client alone will not yield further information.)

Question 14

A client has terminal cancer and the primary care provider has ordered a diagnostic imaging test. The client does not want the test performed so the nurse agrees to dialogue with the primary care provider on the client's behalf. The nurse's actions are what type of intervention? ANSWER: Coordinating (Coordination involves acting as a client advocate, making referrals for follow-up care, collaborating with other health care team members, and ensuring that the client's schedule is therapeutic.)

Question 21

A client in the last stages of pancreatic cancer tells the nurse, "I am tired of fighting. I am ready to die." What is the nurse's best action? ANSWER: Collaborate with other disciplines to plan end-of-life care for the client. (The client has indicated an acceptance of the terminal condition. To respect the client's wishes, the nurse should involve other disciplines, such as hospice care, in planning for the client's needs. )

Question 20

A client who has been in a vegetative state for years is scheduled for an elective surgery. The nurse is questioning whether the procedure is necessary. What is the nurse's appropriate first action? ANSWER: The nurse should address the concern with the surgeon.

Question 4

A client with hypertension being seen for follow-up care has a blood pressure of 160/100. 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? ANSWER: Report the findings to the physician for further plans.

Question 17

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? ANSWER: Prevention of an actual problem (For "risk" nursing diagnoses, the priority goal is to prevent the problem from occurring by implementing interventions that reduce or eliminate risk factors or by collecting additional data. )

Question 6

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? ANSWER: Ask the client to verbalize the medication regimen and diet modifications required.

Question 1

A nurse who is experienced caring only for well babies is assigned to the newborn intensive care nursery (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? ANSWER: The nurse should inform the charge nurse that she does not have the experience to properly care for this client.

Question 18

A registered nurse (RN) and a licensed practical nurse (LPN) are caring for a client who has been admitted with an acute exacerbation of chronic obstructive pulmonary disease (COPD). Which nursing actions can the RN delegate to the LPN? Select all that apply. ANSWER: >Obtaining pulse oximetry >Auscultating breath sounds >Administering an oral antibiotic