Prepu Chapter 17 Implementing

The nurse is attending a conference on evidence-based practice. Which statement by the nurse indicates further education is needed? A)"I must conduct research to validate the usefulness of my nursing interventions." B)"The Agency for Healthcare Research and Quality is a resource for evidence-based practice." C)"Nursing interventions should be supported by a sound scientific rationale." D)"I can learn about evidence-based practice by reading professional nursing journals."

A) "I must conduct research to validate the usefulness of my nursing interventions."

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? A) Ask a skilled nurse to assist with the procedure. B) Read the policy and procedure manual. C) Determine the necessity of the bag change. D) Ask the client how the bag is changed.

A) Ask a skilled nurse to assist with the procedure.

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? A) Discuss possible alternatives to a blood transfusion with the physician. B) Discuss the client's refusal with hospital risk managers. C) Discuss the client's options with other church members. D) Discuss the risks and benefits of a blood transfusion with the client.

A) Discuss possible alternatives to a blood transfusion with the physician.

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 Physician Insurance company Nurse manager

A) Nurse case manager

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? A) Surveillance B) Educational C) Maintenance D) Psychomotor

A) Surveillance

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

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

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? A) Ask the client to verbalize the purpose of the medication. B) Assess the client's blood pressure to determine if the medication is indicated. C) Tell the client to report any side effects experienced. D) Determine the client's reaction to the medication in the past.

B) Assess the client's blood pressure to determine if the medication is indicated.

Which nursing action can be categorized as a surveillance or monitoring intervention? A) Administering a paracetamol tablet B) Auscultating of bilateral lung sounds C) Providing hygiene D) Use of therapeutic communication skills

B) Auscultating of bilateral lung sounds

A client in the last stages of pancreatic cancer tells the nurse, "I am tired of fighting. I am ready to die." What is the nurse's best action? A) Ask if the client would like to speak with a spiritual adviser. B) Collaborate with other disciplines to plan end-of-life care for the client. C) Research other treatment options available for the client. D) Remind the client that positive thoughts are essential for recovery.

B) Collaborate with other disciplines to plan end-of-life care for the client.

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? A) Cost-effectiveness B) Outcome C) Structure D) Process

B) Outcome

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: A) environment and client. B) equipment and personnel. C) skills and assistance. D) logistics and planning.

B) equipment and personnel.

Which examples are essential components for delegating nursing care to an unlicensed assistive personnel (UAP)? Select all that apply. A)The nurse seeks input from the UAP in planning the client's care for the shift. B)The UAP has sufficient knowledge and skill for completing the task. C) The UAP evaluates the client's response after implementing the task and then reports findings to the nurse. D) The UAP can verbalize what information to report to the nurse. E) The nurse has clearly communicated instructions to the UAP.

B)The UAP has sufficient knowledge and skill for completing the task. D) The UAP can verbalize what information to report to the nurse. E) The nurse has clearly communicated instructions to the UAP.

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

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

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

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

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

C) Educate family members about normal growth and development patterns.

A nurse is caring for a postoperative client who reports a pain level of 6 on a scale from 1 to 10. After administering the prescribed pain medication, which intervention should the nurse include in the nursing care plan to monitor and evaluate pain? A) Assess nonpharmacologic modalities used to reduce pain. B) Ambulate the client after administration of pain medication. C) Implement the ABC guide of pain management. D) Review client goals for comfort.

C) Implement the ABC guide of pain management.

Which nursing action would be most effective in helping a client learn self-care behaviors? A) Collect data on the number of self-care activities the client has performed that day. B) Check with the client to ensure that personal self-care goals are being met. C) Model self-care behaviors for the client. D) Ask client to discuss the client's goals for the day at the start of the shift.

C) Model self-care behaviors for the client.

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

C) Praise the client for taking an active role in the client's care.

In the implementation step of the nursing process, which activity is the nurse's first priority? A) Document nursing care. B) Prioritize evaluation of care. C) Reassess client's needs. D) Differentiate between subjective and objective data.

C) Reassess client's needs.

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

C) Risk factors for and prevention of diabetes mellitus

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

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

The nurse is caring for several clients. Which intervention can the nurse direct the unlicensed assistive personnel (UAP) to perform? A)Take the vital signs of the client who just returned from surgery. B)Assist the client who is ambulating the first time since hip replacement surgery. C)Bathe a client with stable angina who has a continuous IV infusing. D)Feed a client who is eating for the first time following an ischemic stroke.

C)Bathe a client with stable angina who has a continuous IV infusing.

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? A) Discuss the client's feelings about the illness. B) Document the client's ambulation. C) Inform the client when ambulation is scheduled next. D) Assess the client's response to the ambulation.

D) Assess the client's response to the ambulation.

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? A) Maintenance B) Collaborative C) Supportive D) Surveillance

D) Surveillance

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 who is pleasantly confused and requires assistance to the bathroom. The client with continuous pulse oximetry who requires pharyngeal suctioning.

D) The client with continuous pulse oximetry who requires pharyngeal suctioning.

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? A) Remind the client that the client is responsible for the client's own health care decisions. B) Ask the surgeon to wait until the client has had a chance to talk to the spouse. C) Inform the surgeon that the nurse will not sign the informed consent form. D)Ask the client whether the client is afraid that the spouse will be angry.

B) 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? A) Assist the client to reposition and splint the incision. B) Assess the client to determine the cause of the pain. C) Consult with the physician for additional pain medication. D) Discuss the frequency of pain medication administration with the client.

B) Assess the client to determine the cause of the pain

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? A) Feedback from the family B) Finances of the client C) The client's condition D) Time and resources

B) Finances of the client

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

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

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? A) "We ask your name to ensure that we are treating the right client." B) "It is a hospital policy to reduce the potential for errors." C) "We ask your name to show that we respect your rights." D) "It is a habit that nurses develop in school."

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

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? A) Identify what barriers the client feels are preventing adherence with the plan. B) Explain the effects of a high-salt diet and smoking on blood pressure. C) Change the nursing care plan. D) Collaborate with other health care professionals about the client's treatment.

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

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

A) 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? A) Medicate the client and wait to ambulate later. B) Explain to the client the benefits of ambulation. C) Emphasize to the client the importance of following the treatment plan. D) Ambulate the client and medicate later.

A) Medicate the client and wait to ambulate later.

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? A) Arrange with the nurse case manager for an early discharge. B) Encourage the client to provide as much self-care as possible. C) Perform all care activities for the client to facilitate rest. D) Teach the family to anticipate the client's needs to care for the client.

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

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? A) Ask the client's family to assist the client in following the plan of care. B) Make changes in the plan of care based upon assessment data. C) Provide information to the client on the benefits of complying with the plan of care. D)Discuss the desired outcomes with the client and the importance of the outcomes.

B) Make changes in the plan of care based upon assessment data.

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? A) A senior nursing student present for clinical B) Nursing assistant who is a nursing student C) Licensed practical nurse D) Registered nurse

B) Nursing assistant who is a nursing student

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? A) Spouse identifies the steps for the dressing change. B) Spouse performs the steps of the dressing change correctly. C) Spouse shows the nurse what supplies are needed. D) Spouse lists the signs of healing.

B) Spouse performs the steps of the dressing change correctly.

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

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

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? A) Provide a video demonstration of abdominal wound care. B) Document client education prior to discharge from the unit. C) Include family members or other caregivers in the education. D) Delegate teaching to unlicensed assistive personnel (UAP).

C) Include family members or other caregivers in the education.

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. A) The client is married. B) The client is male. C) The client is blind. D) The client is an architect. E) The client denies the need for education.

C) The client is blind. E) The client denies the need for education.

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? A) Review the physician's progress notes to determine if any of the tests are not indicated. B) Instruct the client to refuse the diagnostic tests if the client becomes too fatigued. C) Coordinate with the other disciplines to determine if all the tests scheduled are necessary. D) Coordinate with the other disciplines to schedule the tests with adequate rest for the client.

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

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? A) Give the visitors instructions to leave in 10 minutes. B) Leave written information for the client to read later. C) Ask the client if the client has any questions. D) Delay the instruction until the visitors leave.

D) Delay the instruction until the visitors leave.

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? A) The nurse should request that the blood transfusions be delayed until the next shift. B) The nurse should recognize the necessity of the assignment and provide care to the best of the nurse's ability. C) The nurse should ask another nurse who was previously assigned to the client for instruction. D) The nurse should inform the charge nurse that the nurse does not have the experience to properly care for this client.

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

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? A)The nurse is using the standards of care for clients with MIs. B)The nurse is experienced in the needs of clients with MIs. C)The nurse is operating under standing orders for clients with suspected MIs. D)The nurse is ordering what the physician usually orders.

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

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

B) Helping to allay a client's fears about surgery

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? A)"It seems like you are having difficulty with your care regimen." B) "Should I arrange for a home health nurse to coordinate your care?" C) "Should I instruct your family to do the glucose checks for you?" D) "It is extremely important to your health to strictly follow your plan of care."

A)"It seems like you are having difficulty with your care regimen."

A nurse is preparing to educate a client about self-care after cataract surgery. Which should the nurse do first? A)Determine the client's willingness to follow the regimen. B)Instruct the unlicensed assistive personnel on what to teach the client. C)Identify changes from the baseline. D)Ensure physician approval for the education plan.

A)Determine the client's willingness to follow the regimen.

A nurse is catheterizing a client. Which scenario demonstrates steps the nurse would take to ensure client respect and privacy? A) Ask family members to leave the room briefly, close the door, and ask the client if he or she would like a sheet to cover oneself. B) 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. C) Verify the client's identifiable information, explain the procedure to the family, and pull the privacy curtain to allow the client to feel comfortable in having family close by. D) Bring in another nurse to provide support and prevent questionable behaviors, explain the procedure to the client, and close the door and privacy curtain prior to beginning the procedure.

B) 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.

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? A) Review with the client the risks and benefits of surgery. B) Discuss with the client the reasons for declining surgery. C) Ask the client to discuss the decision with family members. D) Notify the physician of the client's refusal.

B) Discuss with the client the reasons for declining surgery.

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. A) The client tells the nurse that the client's spouse will handle the care. B) The client verbalizes understanding of the instructions. C) The client discusses the specifics of what was taught during the session. D) The client is able to answer the nurse's questions. E) The client asks the nurse to repeat the instructions.

B) The client verbalizes understanding of the instructions. C) The client discusses the specifics of what was taught during the session. D) The client is able to answer the nurse's questions.

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? A) To encourage the client to make a healthy food choice B) To give the client the opportunity to actively participate in care C) To save the client the trouble of looking in the menu D) To help the client adhere to the plan

B) To give the client the opportunity to actively participate in care

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

B) help the client achieve optimal levels of health.

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

D) Discontinue the education and attempt at another time..

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? A) Changing the dressing to prevent infection B) Providing medication for agitation C) Repositioning to prevent pressure injuries D) Ensuring that the endotracheal tube is secure

D) Ensuring that the endotracheal tube is secure

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? A) Licensed practical nurse B) A senior nursing student present for clinical C) Registered nurse D) Nursing assistant

D) Nursing assistant

Which task would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? A) Reassess the client's sacrum for redness when doing a bed bath. B) Retrieve a unit of blood from the blood bank. C) Assess an IV site for possible infiltration D) Provide the client with assistance in transferring to the bedside commode.

D) 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? A) Instruct the client that pain medication is available at regular intervals. B) Perform additional nonpharmacological pain interventions. C) Notify the physician that the client has required pain medications. D) Reassess the client to determine the effectiveness of the interventions.

D) Reassess the client to determine the effectiveness of the interventions.

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? A) Interview the family to determine if the client is giving accurate information. B) Reinforce the instructions for the treatment regimen to the client. C) Inform the client that the blood pressure medication will have to be changed. D) Report the findings to the physician for further plans.

D) Report the findings to the physician for further plans.

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? A) Reinforce the instructions for the treatment regimen to the client. B) Interview the family to determine if the client is giving accurate information. C) Inform the client that the blood pressure medication will have to be changed. D) Report the findings to the physician for further plans.

D) 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? A) Consult with the physical therapist to determine the client's ability. B) Continue assisting the client to the bathroom to ensure the client's safety. C) Instruct the client's family to assist the client to ambulate to the bathroom. D) Revise the care plan to allow the client to ambulate to the bathroom independently.

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

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. Perform a full review of systems. Initiate an intravenous line and administer 500mL of normal saline. Discuss the need to change positions slowly, especially when moving from sitting to standing.

Perform vital signs and blood glucose level.

After instituting interventions to increase oxygenation, the client shows no signs of improvement. What is the nurse's priority action? a) Document the interventions and the result. b) Determine the client's code status in case of an emergency. c) Communicate with the physician for additional orders. d) Reassess the client for improvement in 30 minutes.

c) Communicate with the physician for additional orders.