PrepU Chap 17: Implementing
Which parties are essential for the nurse to include in the implementation of a client's plan of care?
Client, family, and physician
A nurse is providing care to several assigned clients and decides to delegate the task of monitoring 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
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.
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 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.
Which nursing action can be categorized as a surveillance or monitoring intervention?
Auscultating of bilateral lung sounds.
The nursing is caring for several clients. Which intervention can the nurse direct the unlicensed assistive personnel (UAP) to perform?
Bathe a client with stable angina who has a continuous IV infusing.
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 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.
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.
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
-Oxygen Saturation lvl increases -States they can breathe easier -respiratory rate decreases
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
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 mostappropriately remedy this conflict?
Communicate with the physicians to coordinate their orders.
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?
Coordinating
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.
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?
Which is the priority question for the nurse to consider before implementing a new intervention?
Does this treatment make sense for this client?
Which action is a nursing intervention that facilitates lifespan care?
Educate family members about normal growth and development patterns.
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 understands 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 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.
A nurse is administering metformin to a client who has a new onset of diabetes mellitus type 2. Which step should the nurse consider a priority on the nursing care plan?
Monitor for lactic acidosis
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
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.
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.
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.
Before implementing any planned intervention, which action should the nurse take first?
Reassess the client to determine whether the action is needed.
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
A client is admitted to the mental health center after attempting suicide. Which client concern is the priority for the nurse to manage?
Risk of self-harm
As part of a client's plan of care, a nurse teaches a client's spouse how to perform a dressing change to the client's abdominal wound. Which method would be most effective to determine whether the spouse has mastered the skill?
Spouse performs the steps of the dressing change correctly.
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 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 has a diagnosis of Risk for Injury related to falls. How would the nurse know if the intervention was successful?
The client is free of falls.
The nurse caring for a client who is recovering after a motor vehicle accident is planning for the client to begin increasing responsibility for self-care. Which would be the nurse's most appropriate strategy?
The nurse encourages the client to take a shower instead of receiving a bed bath.
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
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?
The nurse should address the concern with the surgeon.
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 client tells the nurse, "I think the nurse last night may have given me the wrong medication, but I was afraid to say anything." What is the nurse's most appropriate response?
"You should always speak up if you have any questions about your care."
What are the advantages of using standard Nursing Interventions Classifications (NIC)? Select all that apply
-Allocating nursing resources -Developing information systems -Teaching decision making -Communicating nursing to non-nurses
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.
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.
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 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.
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.
Which statement best explains why continuing data collection is important?
It enables the nurse to revise the care plan appropriately.
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 Care Manager
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
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?
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.
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
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 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 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.
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 mostappropriate 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 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 most appropriate action?
Reschedule the client's bath to the evening shift
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
The home health nurse caring for a client with limited eyesight notes that the client's route to the bathroom is cluttered. What is the most effective way for the nurse to ensure the client's long-term safety?
Assist the client to identify strategies to promote safety in the home.
The nurse is working with a client who is having a difficult time accepting a new diagnosis of type 2 diabetes. The nurse pulls up a chair and holds the client's hand while listening to the client's concerns. What additional type of nursing supportive intervention could the nurse provide?
Arranging for clergy to visit with the client
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.
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 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?
Nursing assistant who is a nursing student
The nurse is attending a conference on evidence-based practice. Which statement by the nurse indicates further education is needed?
"I must conduct research to validate the usefulness of my nursing interventions."
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."
Before implementing a nursing intervention, which question(s) will the nurse ask oneself? Select all that apply.
"Is the client prepared for what needs to be done?" "Do I have all the necessary supplies and equipment needed?" "Do I have the skills to perform the intervention?" "Can I do the intervention alone or do I need help?" "Do any health care provider prescriptions need to be clarified?"
A client with diabetes who has been closely following the prescribed plan of care for over a year is being seen at an outpatient facility. The client has not brought a log of daily glucose checks and tells the nurse, "I haven't been doing them regularly." What is the nurse's most therapeutic statement to the client?
"It seems like you are having difficulty with your care regimen."
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."
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.
Ask the client questions regarding personal care needs. Orient the client and family to the room, including the call light button.
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
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.
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
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.
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.
Which are appropriate guidelines for the nurse to follow when delegating tasks to an unlicensed assistive personnel (UAP)? Select all that apply.
Delegate tasks that are within the UAP's scope of practice. Delegate tasks that involve minimal risk. Provide appropriate supervision when delegating tasks. Provide feedback to the UAP after the task is completed.
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 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 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.
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
A nurse is catheterizing a client. Which scenario demonstrates steps the nurse would take to ensure client respect and privacy?
Explain the procedure to the client, close the door to the room, and cover all areas of the client, only exposing the area for catheterization.
Which is an independent (nurse-initiated) action?
Helping to allay a client's fears about surgery
The nurse ascertains that a client is failing to follow the plan of care that was collaboratively developed. Further investigation determines that the plan of care is not appropriate for this client. What is the nurse's next step in correcting this problem?
Make changes in the plan of care based upon assessment data.
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
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.
A nurse in the intensive care unit (ICU) has been assigned to care for a client who was seriously injured during a gang rape. The nurse was raped 6 months ago and fears being too upset to care for the client properly. How should the nurse deal with the assignment?
Recognize the nurse's own limitations and ask for another nurse to be assigned.
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.
The registered nurse (RN) is delegating the task of assisting a postoperative 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 did the nurse omit?
Right Circumstance
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
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.
