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Terms in this set [45]
The primary purpose of nursing implementation is to:
improve the client's postoperative status.
help the client achieve optimal levels of health.
implement the critical pathway for the client.
identify a need for collaborative consults.
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 registered nurse is working with an unlicensed assistive personnel. Which client should the nurse not delegate to the unlicensed assistive personnel?
The client who requires assistance dressing in preparation for discharge.
The client who needs vital signs taken following infusion of packed red blood cells.
The client who is pleasantly confused and requires assistance to the bathroom.
The client with continuous
pulse oximetry who requires pharyngeal suctioning.
The client with continuous pulse oximetry who requires pharyngeal suctioning.
The nurse needs to perform the pharyngeal suctioning of the client with continuous pulse oximetry. This client requires the nurse to evaluate the client's response in pulse oximetry to the suctioning. The nurse can delegate the other clients to the unlicensed assistive personnel.
The nursing team, consisting of a nurse and experienced unlicensed assistive personnel [UAP], have worked well together for the past year. The nurse instructs the UAP to feed a stable stroke client, assist with dressing a client in preparation for discharge, and take vital signs of a third client in addition to notifying the nurse if the blood pressure becomes low. Which error has the nurse made?
The nurse delegated tasks to the UAP that are outside the scope of that person's preparation.
The
nurse failed to communicate clear instructions regarding what constitutes a low blood pressure.
The nurse failed to validate the UAP's knowledge and skill to perform the tasks.
The nurse delegated too many tasks to the unlicensed assistive personnel.
The nurse failed to communicate clear instructions regarding what constitutes a low blood pressure.
The nurse failed to communicate clear instructions to the UAP. The delegated tasks are not too numerous and are within the scope of a UAP's role and responsibilities. The nurse has had ample opportunity to validate the UAP's knowledge and skill to perform the tasks, as they have worked together for the past year.
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?
Collaborate with the physical therapist to determine the client's ability.
Communicate with the physicians to coordinate their orders.
Assess the client to determine whether the client is capable of ambulation.
Instruct the client to ask the physicians for clarifications of instructions.
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.
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.
Medicate the client with the ordered pain medication.
Determine the frequency of pain medication.
Instruct the client in nonpharmacologic pain management.
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.
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?
Review the physician's progress notes to determine if any of the tests are not indicated.
Coordinate with the other disciplines to schedule the tests with adequate rest for the client.
Instruct the client to
refuse the diagnostic tests if the client becomes too fatigued.
Coordinate with the other disciplines to determine if all the tests scheduled are necessary.
Coordinate with the other disciplines to schedule the tests with adequate rest for the client.
The nurse's most appropriate course of action is to coordinate with the other disciplines to plan the scheduling of the tests with opportunities for the client to rest. Since the tests have been ordered by the physician, the other disciplines and the nurse cannot change the orders without the physician doing so. If the nurse feels that any of the tests are unnecessary, the appropriate course of action would be to consult with the ordering physician. While the client has the right to refuse any treatment, it would be more beneficial to the client if steps were taken earlier to prevent the necessity of the client's refusal.
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?
Medicate the client for anxiety and continue the education later.
Continue the education and remind the client that it is essential to learn self-care.
Discontinue the education and attempt at another time.
Discontinue the education and ask the client for permission
to teach a family member.
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 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.
Tell the client to report any side effects
experienced.
Determine the client's reaction to the medication in the past.
Ask the client to verbalize the purpose of the medication.
Assess the client's blood pressure to determine if the medication is indicated.
Before initiating any intervention, the nurse must determine if the intervention is still necessary. Before administering blood pressure medication, the blood pressure must be assessed. The client's reaction to the medication previously does not indicate if the medication is indicated at this time. The client's ability to verbalize the purpose of the medication is important to promote self-care, but it is not important for the client's safety at this time. The client's report of side effects would indicate an adverse reaction after the medication is administered, but it would not protect the client's safety before the medication is given.
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?
Instruct the client's family to assist the client to ambulate to the bathroom.
Revise the care plan to allow the client to ambulate to the bathroom independently.
Continue assisting the client to the bathroom to ensure the client's safety.
Consult with the physical therapist to determine the client's
ability.
Revise the care plan to allow the client to ambulate to the bathroom independently.
The intervention of assisting the client to the bathroom is no longer indicated, so the nurse would appropriately revise the care plan to discontinue that intervention. A consult with a physical therapist is not necessary to verify the nurse's independent assessment. If the client is safe to ambulate to the restroom independently, it is not necessary for the family to assist.
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?
Remind the client that the client is responsible for the client's own health care decisions.
Inform the surgeon that the nurse will not sign the informed consent form.
Ask the surgeon to wait until the client has had a chance to
talk to the spouse.
Ask the client whether the client is afraid that the spouse will be angry.
Ask the surgeon to wait until the client has had a chance to talk to the spouse.
It is important to consider the client's wishes, so the nurse should advocate for the client and ask the surgeon to wait until the client has talked to the spouse. Telling the client that the client is responsible for the client's own health care decisions does not respect the client's desire to consult the spouse. The client has not expressed being fearful of the spouse. Informing the surgeon that the nurse will not sign the consent form will not satisfy the client's request.
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.
Discuss the client's options with other church members.
Discuss the risks and benefits of a blood transfusion with the client.
Discuss the client's refusal with hospital risk managers.
Discuss possible alternatives to a blood transfusion with the physician.
As coordinator of the client's care, the nurse functions as an intermediary between the physician and the client. In order to honor the client's wishes, the nurse would most appropriately consult with the physician to meet the client's physical needs, as well as the client's spiritual needs. The risk and benefits of a blood transfusion are not the relevant issue with the client. Discussing the client's options with other church members would violate the client's privacy and would not meet the client's physical needs. It might be advisable to discuss the client's refusal of care with the hospital risk manager to protect the legal requirements of the institution, but it is not the priority.
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.
Ask the client how the bag is changed.
Determine the necessity of the bag change.
Read the policy and procedure manual.
Ask a skilled nurse to assist with the procedure.
Professional nurses should only undertake tasks that they have been properly trained to perform. Because the nurse has no experience in changing an ostomy bag, it would be most appropriate to have the assistance of an experienced nurse. It would be inappropriate to ask the client how the bag is changed. The client is relying on the nurse to have the necessary technical knowledge. Reading the policy and procedure manual alone would not ensure the successful completion of the procedure. The necessity of the ostomy bag change has already been established.
Which statement best explains why continuing data collection is important?
It is difficult to collect complete data in the initial assessment.
It is the most efficient use of the nurse's time.
It enables the nurse to revise the care plan appropriately.
It meets current standards of care.
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.
What are the goals of the research that is behind the Nursing Outcomes Classification [NOC] system? Select all that apply.
To teach decision making
To communicate nursing to non-nurses
To evaluate the validity and usefulness of the classification in clinical field testing
To define and test measurement procedures for the outcomes and indicators
To ensure appropriate reimbursement for nursing services
To
identify, label, and validate nursing-sensitive client outcomes and indicators
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
The goals of research behind the NOC are to identify, label, validate, and classify nursing-sensitive client outcomes and indicators; evaluate the validity and usefulness of the classification in clinical field testing; and define and test measurement procedures for the outcomes and indicators. This research continues in an effort to develop a common nursing language to optimize the design and delivery of safe, high-quality, and cost-effective care. Teaching decision making and ensuring proper reimbursement are not goals of the NOC. Communicating nursing to non-nurses is a goal of the Nursing Interventions Classification [NIC].
Which task would be appropriate for the nurse to delegate to an unlicensed assistive personnel [UAP]?
Retrieve a unit of blood from the blood bank.
Reassess the client's sacrum for redness when doing a bed bath.
Provide the client with assistance in transferring to the bedside commode.
Secure the client's jewelry before surgery.
Provide the client with assistance in transferring to the bedside commode.
Assisting with toileting is one of the tasks the state board of nursing permits UAPs to perform. UAPs commonly performed this task in health facilities. Each of the other responses demands a level of responsibility that the nurse cannot legally delegate to a UAP.
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?
Time and resources
Finances of the client
Feedback from the family
The client's condition
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.
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?
Maintenance
Surveillance
Educational
Psychomotor
Surveillance
Surveillance interventions include detecting changes from baseline data and recognizing abnormal response. 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. Educational interventions require instruction, demonstration, and return demonstration of knowledge or a skill set. Psychomotor interventions involve the nurse physically working with the client. Maintenance interventions involve the nurse assisting the client with performing routine activities of daily living.
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?
An older adult with pneumonia who is being discharged to the son's home
tomorrow
A client with a high fever receiving intravenous fluids, antibiotics, and oxygen
A middle-aged client who had abdominal surgery 3 days ago and is ambulating in the hall
An adult client who is being treated for kidney stones
A client with a high fever receiving intravenous fluids, antibiotics, and oxygen
For delegation, the circumstances must be right. The health condition of the client must be stable. The client with a high fever receiving intravenous fluids, antibiotics, and oxygen is the least stable of the clients listed and should be assessed by the nurse. Delegation of taking vital signs would be appropriate for all of the other client's described.
Which is the priority question for the nurse to consider before implementing a new intervention?
Will I need someone to assist me?
What equipment do I need?
Does this treatment make sense for this client?
How
much experience do I have with this treatment?
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.
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?
Maintenance
Surveillance
Supportive
Collaborative
Surveillance
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.
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 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.
The client who needs vital signs taken following infusion of packed red blood cells.
The client with continuous pulse oximetry who requires pharyngeal suctioning.
The nurse needs to perform the pharyngeal suctioning of the client with continuous pulse oximetry. This client requires the nurse to evaluate the client's response in pulse oximetry to the suctioning. The nurse can delegate the other clients to the unlicensed assistive personnel.
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.
Determine the frequency of pain medication.
Instruct the client in nonpharmacologic pain management.
Medicate the client with the ordered pain medication.
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.
What assessment data would indicate to the nurse at the conclusion of an education session that the client education was effective? Select all that apply.
The client is able to answer the nurse's questions.
The client
discusses the specifics of what was taught during the session.
The client tells the nurse that the client's spouse will handle the care.
The client verbalizes understanding of the instructions.
The client asks the nurse to repeat 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 client verbalizes understanding of the instructions.
After an intervention is implemented, the nurse must assess the effectiveness of the intervention. The client stating an understanding of the instructions gives the nurse an indication that learning has taken place. Asking the client questions and receiving the correct answers is an excellent way to judge the client's knowledge. The client asking for the nurse to repeat the instructions shows that the client does not have a clear understanding. The client's statement that the spouse will handle the care signals that the client is not ready to learn at this time. The client's ability to discuss the specifics of the material suggests that learning has taken place.
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.
Instruct the client's family to assist the client to ambulate to the bathroom.
Continue assisting the client to the bathroom to ensure the client's safety.
Consult with the physical therapist to determine the client's ability.
Revise the care plan to allow the client to ambulate to the bathroom independently.
The intervention of assisting the client to the bathroom is no longer indicated, so the nurse would appropriately revise the care plan to discontinue that intervention. A consult with a physical therapist is not necessary to verify the nurse's independent assessment. If the client is safe to ambulate to the restroom independently, it is not necessary for the family to assist.
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?
Ask the client to discuss the decision with family members.
Notify the physician of the client's refusal.
Discuss with the client the reasons for declining surgery.
Review with the client the risks and benefits of surgery.
Discuss with the client the reasons for declining surgery.
The nurse needs further information before deciding what interventions are necessary, so the most appropriate action is to determine the client's reasons for refusal. Until the information is collected, the nurse cannot decide whether reviewing the risks and benefits of surgery would be effective. It is also premature to ask the client to discuss the decision with family members. It is not appropriate to notify the physician until the assessment is complete.
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?
Inform the surgeon that the nurse will not sign the informed consent form.
Ask the client whether the client is afraid that the spouse will be angry.
Remind the client that the client is responsible for the client's own health care decisions.
Ask the surgeon to wait until the client has had a chance to talk to the spouse.
Ask the surgeon to wait until the client has had a chance to talk to the spouse.
It is important to consider the client's wishes, so the nurse should advocate for the client and ask the surgeon to wait until the client has talked to the spouse. Telling the client that the client is responsible for the client's own health care decisions does not respect the client's desire to consult the spouse. The client has not expressed being fearful of the spouse. Informing the surgeon that the nurse will not sign the consent form will not satisfy the client's request.
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
Preparation of insulin for the diabetic client with an elevated blood glucose level
Insertion of a urinary catheter in a client with benign prostatic hypertrophy
Ambulation of the client with a history of falls for the first time after surgery
Bed bath for the newly admitted client who has multiple skin lesions
The safest delegation is to have the UAP bathe the client with skin lesions and report any abnormal findings to the nurse. Preparing insulin is outside of the UAP's scope of practice. The UAP may have the skills to insert an indwelling catheter and ambulate clients, but the clients involved each have qualifiers that complicate the tasks.
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 task
Right person
Right circumstance
Right supervision
Right circumstance
The nurse fails to follow the delegation guideline related to right circumstance. The RN did not assess the client's needs or identify the outcome to be achieved by the task that was delegated. The other guidelines were followed.
A nurse is preparing to educate a client about self-care after cataract surgery. Which should the nurse do first?
Identify changes from the baseline.
Determine the client's willingness to follow the regimen.
Ensure physician approval for the education plan.
Instruct the unlicensed assistive personnel on what to teach the client.
Determine the client's willingness to follow the regimen.
The prerequisite to health education about self-care after cataract surgery is the client's willingness to follow the regimen. Once a nurse is aware of the client's readiness for learning, the nurse can implement outcome-based education plans. Identifying changes from baseline is important for monitoring interventions. Approval by the physician may not be necessary. Delegating the teaching activity to an unlicensed assistive personnel is inappropriate because it is not within the person's scope of practice.
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.
Assist the client to reposition and splint the incision.
Discuss the frequency of pain medication administration with the client.
Consult with the physician for additional pain medication.
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.
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 family asks if the client is going to be okay.
The client states, "I can breathe easier now."
The client's respiratory rate decreases.
The client's oxygen saturation level
increases.
The client is watching television.
The client's respiratory rate decreases.
The client states, "I can breathe easier now."
The client's oxygen saturation level increases.
When reassessing the client after implementing interventions to increase oxygenation, the nurse would look for a decrease in respiratory rate to a more normal rate and an increase in the oxygen saturation level. The client's subjective statement of breathing easier would also indicate effectiveness. The client watching television and the client's family's statement do not indicate anything about oxygenation status.
After instituting interventions to increase oxygenation, the client shows no signs of improvement. What is the nurse's priority action?
Reassess the client for improvement in 30 minutes.
Document the interventions and the result.
Determine the client's code status in case of an
emergency.
Communicate with the physician for additional orders.
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.
While observing a new nurse inserting an indwelling urinary catheter, the preceptor observes a break in sterile technique. What is the preceptor's first action?
Tell the new nurse that a break in sterile technique has occurred and the procedure must be stopped.
Report the new nurse's error to the nurse manager
for corrective action.
Assign the new nurse to view videos on sterile catheter insertion.
Allow the new nurse to continue with the insertion and discuss the error later away from the client.
Tell the new nurse that a break in sterile technique has occurred and the procedure must be stopped.
The most important priority is to ensure the client's safety. Because the new nurse has contaminated the sterile field, the risk of introducing infection is high. The procedure must be discontinued. Because the preceptor is working with the new nurse, it would not be necessary to report the new nurse's error to the nurse manager unless it became a pattern of behavior. Assigning the nurse to watch instructional videos might be appropriate, but after the client care issue is resolved.
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?
Ask the client to discuss the decision with family members.
Notify the physician of the client's refusal.
Review with the client the risks and benefits of surgery.
Discuss with the client the reasons for declining surgery.
Discuss with the client the reasons for declining surgery.
The nurse needs further information before deciding what interventions are necessary, so the most appropriate action is to determine the client's reasons for refusal. Until the information is collected, the nurse cannot decide whether reviewing the risks and benefits of surgery would be effective. It is also premature to ask the client to discuss the decision with family members. It is not appropriate to notify the physician until the assessment is complete.
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 parents verbalize acceptance of the need to closely monitor their child's condition.
The client expresses a desire to learn how to manage the medication regime.
The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years.
The parents have comprehensive insurance coverage for their family's medical care.
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 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
Insurance company
Nurse manager
Physician
The nurse case manager is the expert on resources available for the client's care. The nurse manager is responsible for the operation of the nursing unit. The physician is concerned with the client's medical needs. The insurance company is a possible resource, if the client has insurance coverage.
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?
Process
Cost-effectiveness
Outcome
Structure
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 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.
Perform vital signs and blood glucose level.
A patient who presents with severe dizziness needs a comprehensive assessment, including vital signs and blood glucose level, prior to any other action. The results of the assessment could help determine which actions to take next. Discussing the need to change positions slowly and home blood pressure monitoring may be appropriate educational activities for this client, but the assessment should be performed first to be sure that the client's symptoms are caused by hypotension. The client may also need intravenous fluids to help correct hypotension, but the client must be assessed first.
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
Research findings
Developmental stage
Current standards of care
...
Which nursing intervention is most likely to be allowed within the parameters of a protocol or standing order?
Changing a client's advance directive after the prognosis has significantly worsened
Changing a client's intravenous [IV] fluid from normal saline to 5% dextrose
Administering a beta-adrenergic blocker to a new client whose blood pressure is high on admission assessment
Administering a glycerin suppository to a constipated client who has not responded to oral
stool softeners
...
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?
Order
set
Standing orders
Algorithm
Protocol
...
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?
Ask the client for permission to give the bath in the morning.
Determine whether the nurses have time to give the client's bath at night.
Reschedule the client's
bath to the evening shift.
Tell the client that the physician has ordered sleep medication if necessary.
...
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 show that we respect your rights."
"It is a habit that nurses develop in school."
"It
is a hospital policy to reduce the potential for errors."
"We ask your name to ensure that we are treating the right client."
...
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?
Document the client's ambulation.
Discuss the client's feelings about the illness.
Inform the client when ambulation is scheduled
next.
Assess the client's response to the ambulation.
...
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.
The nurse is ordering what the physician usually orders.
The nurse is experienced in the needs of clients with MIs.
The nurse is using the standards of care for clients with MIs.
...
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