Chapter 17: Implementing

Which statement by a nurse case manager regarding this nurse's role in client care is most accurate? "I provide indirect care to my clients by coordinating their treatment with other disciplines." "Even though I do not provide care to clients, my work is very important." "I provide a critical service that is necessary for financial reimbursement." "Moving away from client care is a necessary step to advancing my career."

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

When the nurse is administering medication, an older adult client states, "Why does everyone keep asking my name? I've been here for days." How should the nurse respond to the client? "It is a habit that nurses develop in school." "It is a hospital policy to reduce the potential for errors." "We ask your name to ensure that we are treating the right client." "We ask your name to show that we respect your rights."

"We ask your name to ensure that we are treating the right client."

Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? Bed bath for the newly admitted client who has multiple skin lesions Preparation of insulin for the diabetic client with an elevated blood glucose level Ambulation of the client with a history of falls for the first time after surgery Insertion of a urinary catheter in a client with benign prostatic hypertrophy

Bed bath for the newly admitted client who has multiple skin lesions

A client on the medical-surgical unit is scheduled for several diagnostic tests. The nurse is concerned that the tests will be too tiring for the client. What would be the nurse's most appropriate action? Coordinate with the other disciplines to schedule the tests with adequate rest for the client. Coordinate with the other disciplines to determine if all the tests scheduled are necessary. Review the health care provider's progress notes to determine if any of the tests are not indicated. Instruct the client to refuse the diagnostic tests if the client becomes too fatigued.

Coordinate with the other disciplines to schedule the tests with adequate rest for the client.

Which statement best explains why continuing data collection is important? It is difficult to collect complete data in the initial assessment. It is the most efficient use of the nurse's time. It enables the nurse to revise the care plan appropriately. It meets current standards of care.

It enables the nurse to revise the care plan appropriately.

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 explains each procedure twice to prevent client questions from wasting time. -The nurse encourages the client to participate in all treatment decisions as the center of the health care team. -The nurse encourages clients to advocate for themselves instead of choosing a trusted family member or friend. -The nurse assures the client who questions a medication that it is the right medication prescribed for him or her and administers the medicine.

The nurse encourages the client to participate in all treatment decisions as the center of the health care team.

The primary purpose of nursing implementation is to: improve the client's postoperative status. identify a need for collaborative consults. help the client achieve optimal levels of health. implement the critical pathway for the client.

help the client achieve optimal levels of health.

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? Educational Psychomotor Maintenance Surveillance

surveillance E: detecting changes from baseline data and recognizing abnormal response

The nurse is coordinating care for a client with continuous pulse oximetry who requires pharyngeal suctioning. To which staff member should the nurse avoid delegating the task of suctioning? registered nurse unlicensed assistive personnel who is in nursing school senior student in nursing school who is present for clinical licensed practical/vocational nurse

unlicensed assistive personnel who is in nursing school

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 the risks and benefits of a blood transfusion with the client. Discuss possible alternatives to a blood transfusion with the health care provider. Discuss the client's options with other church members. Discuss the client's refusal with hospital risk managers.

Discuss possible alternatives to a blood transfusion with the health care provider.

Which action is a nursing intervention that facilitates lifespan care? Educate family members about normal growth and development patterns. Explore factors that could motivate adolescent members of the family to engage in risky behaviors. Identify coping strategies for the family that have worked in the past. Teach contraceptive options for planned pregnancy.

Educate family members about normal growth and development patterns. E:Knowledge of normal growth and development is essential for family members to promote their own health and welfare throughout the lifespan

Which action should the nurse take to ensure that an unlicensed assistive personnel (UAP) understands the instructions to perform a delegated task? -Instruct the UAP to repeat the instructions to be sure the nurse has communicated clearly. -Request that the UAP place the steps of the task in the framework of the nursing process. -Inform the UAP of the importance of following each step listed in the procedure manual. -Ask another UAP to observe and assist the UAP in performing the task.

Instruct the UAP to repeat the instructions to be sure the nurse has communicated clearly.

The emergency room nurse is performing an initial assessment of a new client who presents with severe dizziness. The client reports a medical history of hypertension, gout, and migraine headaches. Which step should the nurse take first in the comprehensive assessment? -Perform vital signs and blood glucose level. -Discuss the need to change positions slowly, especially when moving from sitting to standing. -Perform a full review of systems. -Initiate an intravenous line and administer 500mL of normal saline.

Perform vital signs and blood glucose level.

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? Teach the content again utilizing the same method. Reassess the appropriateness of the method of instruction. Revise the plan to include the inclusion of a support group. Report the client's inability to learn to the case manager.

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. Instruct the client that pain medication is available at regular intervals. Notify the health care provider that the client has required pain medications. Perform additional nonpharmacological pain interventions.

Reassess the client to determine the effectiveness of the interventions.

Which tasks can the nurse appropriately delegate to the unlicensed assistive personnel (UAP)? Select all that apply. Record the client's intake and output. Assess the client's need for education. Assist the client to the bedside commode. Assess the client's risk for pressure injuries. Administer routine oral medications.

Record the client's intake and output. Assist the client to the bedside commode.

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 male. The client is married. The client is blind. The client is an architect. The client denies the need for education.

The client is blind. the client denies the need for education.

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. -The nurse should ask another nurse who was previously assigned to the client for instruction. -The nurse should request that the blood transfusions be delayed until the next shift. -The nurse should recognize the necessity of the assignment and provide care to the best of the nurse's ability.

The nurse should inform the charge nurse that the nurse does not have the experience to properly care for this client.

A nurse is performing a sterile dressing change on a client's abdominal incision. While establishing the sterile field, the nurse drops the forceps on the floor. The nurse is unable to continue with the dressing change because there are no extra supplies in the room, and no one is present to bring new forceps. The nurse failed to organize: equipment and personnel. environment and client. logistics and planning. skills and assistance.

equipment and personnel

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 manager Nurse case manager Health care provider Insurance company

nurse case manager

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. Perform all care activities for the client to facilitate rest. Teach the family to anticipate the client's needs to care for the client. Arrange with the nurse case manager for an early discharge.

Encourage the client to provide as much self-care as possible.

A client is diagnosed with hypertension, placed on a low-sodium diet, and given smoking cessation literature. The nurse observes the client eating from a fast food restaurant bag that a family member brought in and the client states, "I don't think I can do this." What is the nurse's first objective when implementing care for this client? Explain the effects of a high-salt diet and smoking on blood pressure. Identify what barriers the client feels are preventing adherence with the plan. Collaborate with other health care professionals about the client's treatment. Change the nursing care plan.

Identify what barriers the client feels are preventing adherence with the plan.

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? Medications used to treat diabetes mellitus Risk factors for and prevention of diabetes mellitus The severity of the client's disease The cellular metabolism of glucose

Risk factors for and prevention of diabetes mellitus

The registered nurse is working with an unlicensed assistive personnel. Which client should the nurse not delegate to the unlicensed assistive personnel? -The client who needs vital signs taken following infusion of packed red blood cells. -The client who requires assistance dressing in preparation for discharge. -The client with continuous pulse oximetry who requires pharyngeal suctioning. -The client who is pleasantly confused and requires assistance to the bathroom.

The client with continuous pulse oximetry who requires pharyngeal suctioning.

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 gastroenterologist to explain the treatment plan to the client and family again. Ask the client to verbalize the medication regimen and diet modifications required. Ask the nutritionist to give the client strict meal plans to follow. Refer the client to available community resources and support groups.

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

The health care provider 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. Ambulate the client and medicate later. Emphasize to the client the importance of following the treatment plan. Explain to the client the benefits of ambulation.

Medicate the client and wait to ambulate later.

The emergency room (ER) has a strict protocol regarding intramuscular (IM) injection technique. A nurse working in the ER has learned of a new technique to decrease pain with IM injections from the nursing literature and would like to use it. What is the most appropriate way for the nurse to implement the technique? Begin using the technique to determine whether it is effective. Petition to change the protocol based on the new evidence. Ask the ER health care provider to order IM injections with the new technique. Research the protocols at other area emergency rooms.

Petition to change the protocol based on the new evidence.

Nursing interventions for the client after prostate surgery include assisting the client to ambulate to the bathroom. The nurse concludes that the client no longer requires assistance. What is the nurse's best action? Revise the care plan to allow the client to ambulate to the bathroom independently. Continue assisting the client to the bathroom to ensure the client's safety. Consult with the physical therapist to determine the client's ability. Instruct the client's family to assist the client to ambulate to the bathroom.

Revise the care plan to allow the client to ambulate to the bathroom independently.

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's respiratory rate decreases. The client states, "I can breathe easier now." The client's oxygen saturation level increases. The client is watching television. The client's family asks if the client is going to be okay.

The client's respiratory rate decreases. The client states, "I can breathe easier now." The client's oxygen saturation level increases.

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? registered nurse unlicensed licensed personnel senior student in nursing school who is present for clinical licensed practical/vocational nurse

unlicensed licensed personnel

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? A client with a high fever receiving intravenous fluids, antibiotics, and oxygen An older adult with pneumonia who is being discharged to the son's home tomorrow A middle-aged client who had abdominal surgery 3 days ago and is ambulating in the hall An adult client who is being treated for kidney stones

A client with a high fever receiving intravenous fluids, antibiotics, and oxygen

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? Continue the education and remind the client that it is essential to learn self-care. Medicate the client for anxiety and continue the education later. Discontinue the education and attempt at another time. Discontinue the education and ask the client for permission to teach a family member.

Discontinue the education and attempt at another time.

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. Determine the frequency of pain medication. Medicate the client with the ordered pain medication. Instruct the client in nonpharmacologic pain management.

Go to the client and assess the client's pain.

Which is an independent (nurse-initiated) action? Executing health care provider orders for a catheter Meeting with other health care professionals to discuss a client Helping to allay a client's fears about surgery Administering medication to a client

Helping to allay a client's fears about surgery

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? Inform the client that it is not necessary to wash hands before vital signs. Reassure the client that the nurse knows when to perform hand hygiene. Praise the client for taking an active role in the client's care. Tell the client that gloves are required for this procedure.

Praise the client for taking an active role in the client's care. E: Clients should be empowered to take responsibility for self-care. All clients should be taught that they have the power to question any part of their care