Exam 14: Implementing

The American Nurses Association recommends adherence to defined principles when delegating care tasks to unlicensed assistive personnel. According to these principles, who is responsible and accountable for nursing practice?

An older adult client is receiving care on a rehabilitative medicine unit during her recovery from a stroke. She complains that the physical therapist, occupational therapist, neurologist, primary care physician, and speech language pathologist "don't seem to be on the same page" and that "everyone has their own plan for me." How can the nurse best respond to the client's frustration?

Each time a nurse administers an insulin injection to a client with diabetes, she tells the client what she is doing and demonstrates each step of preparing and giving the injection. What is the nurse promoting in the client?

A graduate nurse recently attended a conference on acute coronary syndrome. In preparing a plan of care for a client admitted with acute coronary syndrome, the nurse considers the information she learned at the conference. Which nursing variable is the nurse utilizing in the development of the plan of care?

Which of the following statements accurately describes a recommended guideline for implementation? Select all that apply.

A male client 30 years of age is postoperative day 2 following a nephrectomy (kidney removal) but has not yet mobilized or dangled at the bedside. Which of the following is the nurse's best intervention in this client's care?

The nurse is assessing a client with a diagnosis of hypertension. The client's blood pressure is 178/88, an increase from 134/78 at the previous clinic visit. The nurse asks the client what has changed from the previous visit. Which client statement identifies a potential factor interfering with the plan of care?

The nurse is trying to determine factors influencing a client who is not following the plan of care. Which client statement identifies a potential factor interfering with following the plan of care? Select all that apply.

A nurse is changing a sterile pressure ulcer dressing based on an established protocol. What does this mean?

A client being prepared for discharge to his home will require several interventions in the home environment. The nurse informs the discharge planning team, consisting of a home health care nurse, physical therapist, and speech therapist, of the client's discharge needs. This interaction is an example of which professional nursing relationship?

Which example reflects client variables that influence outcome achievement? Select all that apply.

The nurse is caring for a client with a diagnosis of end-stage renal disease. The client has expressed the desire to be kept comfortable and to not continue further treatment. The daughter arrives from out of town and is demanding to have further testing done to determine the best treatment option for the client. What is the best action for the nurse to take at this time?

A client who was previously awake and alert suddenly becomes unconscious. The nursing plan of care includes an order to increase oral intake. Why would the nurse review the plan of care?

Many of the homeless clients who are supposed to receive care for HIV/AIDS miss their appointments at a clinic because it is located in a high-rise building on a university campus. Several of the clients state that the clinic is difficult to find and in an intimidating environment. This demonstrates that which of the following variables influencing outcome achievement is being inadequately addressed?

The nurse is caring for a client with a diagnosis of colon disease. The client has expressed to various members of the health care team the desire to be kept comfortable and to not continue further treatment. The client asks the nurse to be present when the client discusses the decision with other family members. In which professional nursing relationship is the nurse participating?

What is the unique focus of nursing implementation?

A nurse delegates a specific intervention to a UAP. What implications does this have for the nurse?

Nursing students need to learn to nurse themselves in order to prepare to be professional nurses. Which activities would fail to prepare nursing students for the delivery of nursing care?

A female client 89 years of age has been admitted to the hospital with a diagnosis of failure to thrive. She has become constipated in recent days, in spite of maintaining a high fluid intake and taking oral stool softeners. She admits to her nurse that the problem is rooted in the fact that she feels mortified to attempt a bowel movement on a commode at her bedside where staff and other clients can hear her. The nurse should respond by modifying which of the following resources?

The nurse overhears two nursing students talking about nursing interventions. Which statement by one of the nursing students indicates further education is required?