Chapter 17: Implementing - Fundamentals of Nursing
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."
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?
"We ask your name to ensure that we are treating the right client."
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
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
Which parties are essential for the nurse to include in the implementation of a client's plan of care?
Client, family, and physician
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 mostappropriate action?
Coordinate with the other disciplines to schedule the tests with adequate rest for the client.
The nurse is preparing a client to be discharged from the surgical unit following abdominal surgery. Which intervention will the nurse use to ensure the client's adherence to proper wound care techniques?
Include family members or other caregivers in the education.
The nurse is preparing a client with a bowel obstruction for emergency surgery. Which intervention has the highest priority for this client?
Inform the client what to expect after the surgery.
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
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 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 registered nurse is working with an unlicensed assistive personnel. Which client should the nurse not delegate to the unlicensed assistive personnel?
The client with continuous pulse oximetry who requires pharyngeal suctioning.
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 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.
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."
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.
1.) The client's respiratory rate decreases. 2.) The client states, "I can breathe easier now." 3.) The client's oxygen saturation level increases.
The surgeon is insisting that a client consent to a hysterectomy. The client refuses to make a decision without the consent of the client's spouse. What is the nurse's best course of action?
Ask the surgeon to wait until the client has had a chance to talk to the spouse.
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
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 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.
The nurse is preparing a client for surgery when the client tells the nurse that the client no longer wants to have the surgery. How should the nurse most appropriately respond?
Discuss with the client the reasons for declining surgery.
Which action is a nursing intervention that facilitates lifespan care?
Educate family members about normal growth and development patterns.
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
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.
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 task would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)?
Provide the client with assistance in transferring to the bedside commode.
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.
Which tasks can the nurse appropriately delegate to the unlicensed assistive personnel (UAP)? Select all that apply.
Record the client's intake and output. Assist the client to the bedside commode.
A client with hypertension being seen for follow-up care has a blood pressure of 160/100 mm Hg. 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?
Report the findings to the physician for further plans.
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.
The nurse is caring for a postoperative client who is receiving morphine sulfate for pain management. The nurse obtains the following vital signs: heart rate, 74 beats/min; respiratory rate, 8 breaths/min; blood pressure, 114/68 mm Hg. After reviewing the nursing care plan and physician orders, the nurse administers naloxone. Which would allow the nurse to initiate this action?
Standing orders
While observing a new nurse inserting an indwelling urinary catheter, the preceptor observes a break in sterile technique. What is the preceptor's first action?
Tell the new nurse that a break in sterile technique has occurred and the procedure must be stopped.
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 is able to answer the nurse's questions. The client discusses the specifics of what was taught during the session. The client verbalizes understanding of the instructions.
The primary purpose of nursing implementation is to:
help the client achieve optimal levels of health.
A nurse is caring for a client with burns. Place the steps in the appropriate order for providing wound care for the client. Use all options.
1.) Remove old dressing. 2.) Assess condition of wound. 3.) Obtain a culture. 4.) Open sterile dressing tray. 5.) Change from clean to sterile gloves. 6.) Record color and odor of discharge.
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.
1.) The client is blind. 2.) The client denies the need for education.
