Chapter 15: Implementation and Evaluation
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."
The nurse overhears two nursing students talking about nursing interventions. Which statement by one of the nursing students indicates further education is required?
"Nursing interventions must be approved by other members of the health care team."
A nurse is educating a client on how to administer insulin, with the expected outcome that the client will be able to self-administer the insulin injection. How would this outcome be evaluated?
Ask the client to demonstrate self-injection of insulin.
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 has assisted the client to ambulate for the first time. After returning the client to bed, what is the nurse's priority intervention?
Assess the client's response to the ambulation.
Nurses formulate different types of goals for clients when planning client care. What is considered a psychomotor client goal?
By 18AUG2015, client will demonstrate improved motion in left arm.
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 intravenous fluids, antibiotics and oxygen
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.
The nurse is caring for a client who is recovering from a cerebrovascular accident (CVA). When reviewing the client's orders, the nurse notes that one of the physicians wrote orders to ambulate the client, while 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.
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 the instruction until the visitors leave.
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.
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.
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
A busy nurse is working with an unlicensed assistive personnel (UAP). What tasks can the nurse appropriately delegate to the UAP? Select all that apply.
Record the client's intake and output. Assist the client to the bedside commode.
Nurse Mayweather is auscultating lung sounds. She notes crackles in the LLL which were not present at the start of the shift. Nurse Mayweather is engaged in which type of nursing intervention?
Surveillance intervention
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 discusses the specifics of what was taught during the session. The client verbalizes understanding of the instructions. The client is able to answer the nurse's questions.
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.
Which nurse is using criteria to determine expected standards of performance?
The new graduate nurse consults the policies and procedures of the institution prior to skill implementation.
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?
The nurse should inform the charge nurse that she does not have the experience to properly care for this client.
Which nursing action reflects ANA and CNA Standards of Practice regarding implementation?
The nurse uses community resources to implement the plan.
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
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
A nurse manager is conducting peer reviews of the staff on the critical care unit. Which person would the nurse manager select to evaluate a registered nurse who is certified in critical care?
Another registered nurse with critical care certification
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.
A client, 89 years of age, has been admitted to the hospital with a diagnosis of failure to thrive. The client has become constipated in recent days, in spite of maintaining a high fluid intake and taking oral stool softeners. The client admits to the nurse that the problem is rooted feeling mortified to attempt a bowel movement on a commode at the bedside, where staff and other clients can hear. The nurse should respond by modifying which resource?
Environment
A nurse who has been employed by the facility is scheduled for an evaluation by a group of nurses with similar education and experience. The nurse most likely is undergoing what?
Individual peer review
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.
Obtaining pulse oximetry Auscultating breath sounds Administering an oral antibiotic
What activity is carried out during the implementing step of the nursing process?
Planned nursing actions (interventions) are carried out.
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.
A male client has been recently diagnosed with diabetes after receiving emergency treatment for a hyperglycemic episode. Which of the client's actions indicates that he has achieved a cognitive outcome in the management of his new health problem?
The client is able to explain when and why he needs to check his blood sugar.
Why are quality-assurance programs important in nursing?
They enable nursing to be accountable for the quality of care.
A nurse is changing a sterile pressure injury dressing based on an established protocol. What does this mean?
Written plans are developed that specify nursing activities for this skill.
In order to successfully implement the plan of care, what parties are essential for the nurse to include?
client, family, and physician
The client's expected outcome is "The client will maintain skin integrity by discharge." Which measure is best in evaluating the outcome?
condition of the skin over bony prominences
The nurse assigned to care for a client who has received a sedative has asked the unlicensed assistive personnel (UAP) to help the client to the toilet. The nurse demonstrates proper delegation skills by performing which actions? Select all that apply.
confirming the UAP has successfully passed this skill competency being available for questions from the UAP giving a report on the client to the UAP and answering questions confirming that the UAP has repeatedly completed similar tasks
The terms "criteria" and "standard" are often used interchangeably but actually have distinct, separate definitions. "The levels of performance accepted by, and expected of, nursing staff or other health team members" is known as:
standards.
A client, who was previously awake and alert, suddenly becomes unconscious. The nursing plan of care includes an order to increase oral intake. Why would the nurse review the plan of care?
to be sure the intervention is safe
What is one advantage of having a standard classification of nursing interventions?
to standardize nomenclature (names or terms)
An older adult client is receiving care on a rehabilitative medicine unit during her recovery from a stroke. She voices frustration that the physical therapist, occupational therapist, neurologist, primary care physician, and speech language pathologist "don't seem to be on the same page" and that "everyone has their own plan for me." How can the nurse best respond to the client's frustration?
Facilitate communication between the different professionals and attempt to coordinate care.
Nurses have identified the following outcome in the care of a client who is recovering from a stroke: "Client will ambulate 100 ft (30 m) without the use of mobility aids by 12DEC." Several nurses have evaluated the client's progression towards this outcome at various points during care. Which evaluative statement is most appropriate?
"12DEC - Outcome partially met. Client ambulated 75 ft (22.5 m) without the use of mobility aids"
A nursing student asks the clinical instructor to explain the difference between quality improvement and quality assurance. Which response by the clinical instructor is appropriate?
"Quality improvement focuses on processes, data, and statistical thinking."
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 states, "I can breathe easier now." The client's oxygen saturation level increases. The client's respiratory rate decreases.
The focus of a hospital's current quality assurance program is a comparison between the health status of clients upon admission and at the time of discharge. This form of quality assurance is characteristic of:
outcome evaluation
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:
standard orders
