PrepU Chapter 17: Implementing

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.

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

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

The nurse is caring for a vegetarian who has iron deficiency anemia. The standardized nutritional plan for a client with anemia calls for the client to increase consumption of animal protein. How should the nurse plan to meet this client's nutritional needs? A. Arrange for animal protein to be disguised in the client's meal. B. Meet with the client's family to emphasize the importance of nutritional modification. C. Collaborate with the nutritionist to modify the nutritional plan. D. Instruct the client that consumption of animal protein is necessary to cure the anemia.

C. Collaborate with the nutritionist to modify the nutritional plan.

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

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

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

D. Discuss possible alternatives to a blood transfusion with the physician.

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

D. Nursing assistant

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

D. Provide the client with assistance in transferring to the bedside commode.

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

A. Ask the surgeon to wait until the client has had a chance to talk to the spouse.

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

A. Ensuring that the endotracheal tube is secure

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

A. It enables the nurse to revise the care plan appropriately.

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. Make changes in the plan of care based upon assessment data. B. Ask the client's family to assist the client in following the plan of care. 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.

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

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. Ambulate the client and medicate later. D. Emphasize to the client the importance of following the treatment plan.

A. Medicate the client and wait to ambulate later.

An indwelling urinary catheter has been ordered for a client experiencing urinary retention after surgery. When the nurse enters the room to place the catheter, the client reports voiding in the bathroom. Which is the nurse's most appropriate action? A. Reassess whether the client still needs the urinary catheter. B. Inform the client that the catheter will no longer be necessary. C. Insert the urinary catheter as ordered to relieve the urinary retention. D. Instruct the client that the catheter is essential to check for urinary retention.

A. Reassess whether the client still needs the urinary catheter.

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

A. Report the findings to the physician for further plans.

The client is about to have blood drawn before seeing the health care provider. The spouse, while smiling and holding the client's hand, states, "Here comes the blood sucker. It is going to hurt bad." This statement is an example of which type of intervention? Select all that apply. A. Supportive B. Coordinating C. Technical D. Psychosocial E. Physical

A. Supportive D. Psychosocial E. Physical

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

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

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

A. The client with continuous pulse oximetry who requires pharyngeal suctioning.

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.

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. Coordinate with the other disciplines to schedule the tests with adequate rest for the client. C. Instruct the client to refuse the diagnostic tests if the client becomes too fatigued. D. Coordinate with the other disciplines to determine if all the tests scheduled are necessary.

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

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? A. Current standards of care B. Psychosocial background C. Research findings D. Developmental stage

B. Psychosocial background

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? A. Recognize the nurse's own limitations and ask another nurse to assist if the nurse becomes too emotional. B. Recognize the nurse's own limitations and ask for another nurse to be assigned. C. Recognize the issue and care for the client to the best of the nurse's ability. D. Recognize that the nurse may be faced with this issue again and care for the client.

B. Recognize the nurse's own limitations and ask for another nurse to be assigned.

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

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

A nurse who is experienced caring only for well babies is assigned to the neonatal intensive care unit (NICU) because of a shortage of nurses in the NICU. The nurse is assigned to an infant on a ventilator who will require blood transfusions during the shift. What is the nurse's most appropriate course of action? A. The nurse should request that the blood transfusions be delayed until the next shift. B. The nurse should inform the charge nurse that the nurse does not have the experience to properly care for this client. C. The nurse should recognize the necessity of the assignment and provide care to the best of the nurse's ability. D. The nurse should ask another nurse who was previously assigned to the client for instruction.

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

Which nursing intervention is most likely to be allowed within the parameters of a protocol or standing order? A. Changing a client's intravenous (IV) fluid from normal saline to 5% dextrose B. Changing a client's advance directive after the prognosis has significantly worsened C. Administering a glycerin suppository to a constipated client who has not responded to oral stool softeners D. Administering a beta-adrenergic blocker to a new client whose blood pressure is high on admission assessment

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

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? A. Collaborate with the physical therapist to determine the client's ability. B. Instruct the client to ask the physicians for clarifications of instructions. C. Communicate with the physicians to coordinate their orders. D. Assess the client to determine whether the client is capable of ambulation.

C. Communicate with the physicians to coordinate their orders.

A client is admitted to the mental health center after attempting suicide. Which client concern is the priority for the nurse to manage? A. Feelings of not belonging B. Low self-esteem C. Risk of self-harm D. Lack of support

C. Risk of self-harm

One hour after receiving pain medication, a postoperative client reports intense pain. What is the nurse's appropriate first action? A. Discuss the frequency of pain medication administration with the client. B. Consult with the physician for additional pain medication. C. Assist the client to reposition and splint the incision. D. Assess the client to determine the cause of the pain.

D. Assess the client to determine the cause of the pain.

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. Identify coping strategies for the family that have worked in the past. D. Educate family members about normal growth and development patterns.

D. Educate family members about normal growth and development patterns.