Chapter 17: Implementing PrepU

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."

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 nursing intervention is most likely to be allowed within the parameters of a protocol or standing order?

Administering a glycerin suppository to a constipated client who has not responded to oral stool softeners

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 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.

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

A home care client with dementia has the nursing diagnosis "Wandering." Which expected client outcome most directly demonstrates resolution of the problem?

Client will not leave the premises without a caregiver.

The nurse is caring for a client who is recovering from a cerebrovascular accident. When reviewing the client's orders, the nurse notes that one of the physicians wrote orders to ambulate the client, whereas 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. As coordinator of care, the nurse is responsible for ensuring the continuity of the treatment plan. If conflicts occur in the treatment plan, the nurse should first consult with the physicians who have written the conflicting orders. The nurse may assess the client to determine whether the client is capable of ambulation, but this does not resolve the conflict or determine whether ambulation is in the client's best interest. It is not the client's responsibility to clarify nursing orders. Collaboration with the physical therapist could become part of the plan later, but the physicians' orders have to be clarified first.

Which intervention performed by the nurse is appropriate for assisting a client in meeting physiological needs based on Maslow's Hierarchy of Needs?

Cutting up food and opening drink containers for the client

A nurse is preparing to educate a client about self-care after cataract surgery. Which should the nurse do first?

Determine the client's willingness to follow the regimen.

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 is the nurse's priority question to consider prior to delegating a task to an unlicensed assistive personnel (UAP)?

Does this task fall within the scope of a UAP? All of these questions are important, but the priority is whether the task falls within the scope of a UAP. If the answer is no, the rest of the questions are not necessary.

Which action is a nursing intervention that facilitates lifespan care?

Educate family members about normal growth and development patterns. Knowledge of normal growth and development is essential for family members to promote their own health and welfare throughout the lifespan, and to facilitate family functioning. Childbearing care includes interventions to assist in understanding and coping with psychological and physiologic changes during the childbearing period. Coping assistance includes interventions to assist the client in building on his or her strengths, to adapt to a change in function, or to achieve a higher level of function. Risk management includes interventions to initiate risk reduction activities.

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.

The nurse in a burn intensive care unit (BICU) is caring for a 3-year-old child who was burned with scalding hot water. The client has burns covering 75% of the body. The client's condition is critical but stable. At 1000, the nurse reassesses the client and finds that the client is agitated and pulling at the endotracheal tube. Which is the nurse's priority intervention for this client at this time?

Ensuring that the endotracheal tube is secure

Which actions should the nurse perform during the planning step of the nursing process? Select all that apply.

Establishing priorities Identifying expected client outcomes Selecting evidence-based nursing interventions Communicating the plan of nursing care

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 The client's condition, time and resources, and feedback or input from the family are all of great value when the nurse is prioritizing the client's nursing diagnoses. The client's finances, however, should not influence the nurse's priority setting. The nursing code of ethics states that clients should receive the same treatment regardless of their ability to pay.

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?

Identify what barriers the client feels are preventing adherence with the plan. The nurse must first identify why the client is not following the therapy before collaboration with other health care professionals or a change in the nursing care plan can be initiated. Simply explaining the effects of a high-salt diet and smoking on the blood pressure may not address the underlying cause of why the client is choosing not to follow the recommended care.

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. It is most appropriate to manage the client's pain first. The client will be able to ambulate more easily and it is not necessary to cause the client further pain. Ambulating first considers the needs of the nurse, not the client. The client has not indicated misunderstanding of benefits or the importance of ambulation.

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

Before implementing any planned intervention, which action should the nurse take first?

Reassess the client to determine whether the action is needed.

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 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 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 Why: 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.

The client reports right knee pain of 6/10 on the pain scale and requests medication. The nurse assesses and flushes the intravenous site. Which type of intervention skill is the nurse using?

Technical skill Technical skills are used to carry out treatments and procedures, such as assessing and flushing an intravenous site. Nurses learn the specific skills through clinical practice. Intellectual skills include the ability to explain complex disease processes and treatment regimens to a client. Interpersonal skills, such as communication, allow the nurse to establish strong relationships and build trust with the client. Mechanical skills are not among the skills nurses need.

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 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 blind. The client denies the need for education.

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.

A client has been admitted to the hospital for the treatment of exacerbation of chronic obstructive pulmonary disease. Which statement constitutes a long-term outcome for this client?

The client will return home able to conduct activities of daily living (ADLs) without experiencing shortness of breath.

What are the goals of the research that is behind the Nursing Outcomes Classification (NOC) system? Select all that apply.

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

Which outcome statements are in the cognitive realm? Select all that apply.

Within 1 week after teaching, the client will list three benefits of quitting smoking. After viewing the film, the client will verbalize four benefits of daily exercise. By 6/8/20, the client will describe a meal plan that is high in fiber.

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 best response?

Work with the evening shift to possibly reschedule.

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."

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."

An unlicensed assistive personnel (UAP) has worked on the postpartum unit for many years. The UAP has been oriented well and provides excellent client care. What duties could the professional nurse appropriately delegate to the UAP? Select all that apply.

Assisting the client with personal hygiene needs and ambulation Transporting the infant to the mother's room according to hospital policy It is essential when delegating duties that the registered nurse (RN) is aware the nurse's role and what duties can be delegated. The nurse also must be aware of the training and the competence of the UAP. The nurse could appropriately delegate assisting with personal hygiene needs, ambulation, and transporting the infant to the mother's room according to hospital policy. Assessment is the role of the RN and cannot be delegated. Teaching, including breastfeeding education and discharge instructions, is also the role of the RN and cannot be delegated.

A nurse is catheterizing a client. Which scenario demonstrates steps the nurse would take to ensure client respect and privacy?

Close the door to the room, explain the procedure to the client, and cover all areas of the client, only exposing the area for catheterization.

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 discharge needs of this client are complicated, and the nurse will need the assistance of other disciplines to make a successful discharge plan. The client should have input into the future living arrangements, but the client does not have the resources to make the arrangements alone. The physician may be involved in the discharge plan, but additional orders are not necessary. It is not true (and would be inappropriate) to tell the family that discharge plans cannot be changed. If the family is unwilling to take the client, the placement will be unsuccessful.

After instituting interventions to increase oxygenation, the client shows no signs of improvement. What is the nurse's priority action?

Communicate with the physician for additional orders. If the nurse's interventions have been ineffective, the physician must be notified of the client's deteriorating status. The physician can direct other medical interventions. Documenting the interventions does not take priority over the client's physiologic needs. Allowing another 30 minutes to elapse before taking action will only cause further deterioration in the client's status. The nurse should know the client's code status when taking over the client's care.

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. The nurse should always perform client education when the client is receptive of the education. The client verbalizes not being ready to learn, so education should be discontinued and continued at another time. Asking for permission to teach a family member does not encourage the client to learn self-care and acquire independence. The client does not need medication for anxiety at this time. This is a normal reaction. It would not be productive to continue the education because the client is not ready to learn.

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 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 The nurse should avoid delegating the dressing change to the nursing assistant. The dressing change would be within the scope of practice of the registered nurse, licensed practical nurse, and the senior nursing student.

After learning about a client's limited financial resources and limited insurance benefits, the home care nurse modifies nursing interventions related to a client's care instructions. The nurse modifies the plan of care based upon which client variable?

Psychosocial background The nurse is demonstrating an awareness of the client's psychosocial background, which includes consideration of the client's socioeconomic status. Research findings and current standards of care are examples of nursing variables. The developmental stage is a client variable that addresses the developmental needs of a 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.

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 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 is discussing dietary options with a client who is upset due to not being able to have foods the client 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?

To give the client the opportunity to actively participate in care

One of the primary factors that the nurse considers when setting priorities for the client in the acute care setting after cardiac surgery is the client's:

condition

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.

The primary purpose of nursing implementation is to:

help the client achieve optimal levels of health. The purpose of the nursing implementation phase is to help the client achieve an optimal level of health. Improving the client's postoperative status and implementing the critical pathway for the client are too narrow to represent the purpose of the implementation phase, although they are purposes of specific interventions that would be implemented during this phase. Identifying the need for collaborative consults is an action the nurse would perform in the planning phase of the nursing process.

The nurse should derive the outcomes for a client's care plan from:

the problem statement of the nursing diagnosis.

Which is the priority question for the nurse to consider before implementing a new intervention?

Does this treatment make sense for this client? All of these questions are important, but the priority is whether the treatment makes sense for the client. If not, answering the other questions is unnecessary.

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 .The nurse's first action should always be to determine the cause of the client's pain in order to determine the correct intervention. After determining the cause, the nurse can plan how to proceed. The other steps would be appropriate, but only after the assessment.

These nursing diagnoses appear on a client's care plan. Place in the order in which the nurse will prioritize acting upon them. Use all options.

Impaired Swallowing Fluid Volume Deficit Risk for Impaired Skin Integrity Altered Body Image

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 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. If the family has experience caring for a child with a seizure disorder, the family would already have some basic knowledge, so the nurse would address the education differently. The client expressing a desire to learn indicates receptiveness to the education. The parents' acceptance of their child's condition indicates that they are ready to begin dealing with the child's condition. The fact that the child has comprehensive insurance coverage is a strength that will make options available to the family, but will not necessarily change the nurse's educational plan.

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.

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. One hour after administering pain medication, the nurse would expect the client to be relieved of pain. A new report of intense pain might signal a complication and requires a thorough assessment. The nurse might request an order for additional pain medication, but only after a thorough assessment. Telling the client how often medication can be received does not help relieve the client's pain. Repositioning and splinting the incision are interventions that the nurse might perform, but only after determining the cause of the pain.

Which statement best explains why continuing data collection is important?

It enables the nurse to revise the care plan appropriately. Continuous data collection ensures that the nurse has the most current client data to evaluate, which allows for updating the care plan as needed. A complete assessment is performed on admission, but the client's condition is always changing. The purpose of continued data collection is to provide good client care; it does not relate directly to efficiency of nursing care. While continuous data collection meets standards of care, it is not the primary reason for ongoing assessments.

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 Outcome evaluation focuses on measurable changes in the health status of the client or the end results of nursing care, such as an expedited discharge of the client based on the client recovering more quickly due to an intervention. The focus of a process evaluation is the nature and sequence of activities carried out by nurses implementing the nursing process. A structure evaluation or audit focuses on the environment in which care is provided. Cost-effectiveness is not a type of evaluation identified by the American Nurses Association.

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.

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?

Reassess the appropriateness of the method of instruction. It is the nurse's responsibility to revise the plan of care if an intervention is not successful. The most appropriate action of the nurse would be to determine if the initial education was the most effective for this client. Simply teaching the content again without reassessing the client's needs would not necessarily be effective. A support group might be helpful, but not until the client's needs are evaluated. The case manager is not responsible for the client's learning.

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 Why: Surveillance nursing interventions include detecting changes from baseline data and recognizing abnormal responses. Nurses rely on the senses to detect changes, such as observing the appearance and characteristics of clients and hearing by auscultation, pitch, and tone. Nurses use these surveillance activities to determine the current status of clients and changes from previous states. Maintenance nursing interventions involve the nurse assisting the client with performing routine activities of daily living. Supportive nursing measures involve providing basic comfort and emotional care to the client. Collaborative nursing interventions involve coordination and communication with health care professionals in other fields to meet the client's needs.

A client is on the surgical unit following resection of an intestinal tumor. The client is alert and oriented x3. Based on an assessment of the client, the physician writes a medical order to "ambulate with assistance" in the chart. This will be the client's first time ambulating. Which is the best nursing outcome for this client?

The client will ambulate with the assistance of a walker without falling within the next 4 hours. Nursing outcomes should include five components: subject, verb, conditions, performance criteria, and target time. There is only one answer option that includes all five components: the client (subject) will ambulate (verb) with the assistance of a walker (condition) without falling (performance criterion) within the next 4 hours (time frame). The answer option "Physical therapy will be consulted to assist the client with ambulation" does not properly identify the client as the subject or ambulate as the verb (action). The other two answer options lack performance criteria and indicate time frames that are less specific.

When caring for a client in the emergency room who has presented with symptoms of a myocardial infarction (MI), the nurse orders laboratory tests and administers medication to the client before the physician has examined the client. For the nurse to be operating within the nurse's scope of practice, what conditions must be present?

The nurse is operating under standing orders for clients with suspected MIs.