Ch19 Implementing Nursing Care (Fundamentals)

A nurse is assigned to five patients, including one who was recently admitted and one returning from a diagnostic procedure. It is currently mealtime. The other three patients are stable, but one has just requested a pain medication. The nurse is working with an assistive personnel. Which of the following are appropriate delegation actions on the part of the nurse? (Select all that apply.)

• The nurse directs the assistive personnel to obtain a set of vital signs on the patient returning from the diagnostic procedure.

• The nurse directs the patient care technician to go to the patient in pain and to reposition and offer comfort measures until the nurse can bring an ordered analgesic to the patient.

• The nurse directs the patient care technician to set up meal trays for patients

• The nurse directs the patient care technician to gather a history from the newly admitted patient about his medications

• The nurse directs the patient care technician to assist one of the stable patients up in a chair for his meal.

A nurse working the evening shift has five patients and is teamed up with an assistive personnel. One of the assigned patients has just returned from surgery, three others are stable and resting, and one has requested a pain medication. The patient in pain has two analgesics ordered prn for pain and has been using cold applications on his surgical site for pain relief. The last time an analgesic was given was 4 hours ago. The patient is scheduled for a physical therapy visit in 2 hours. Which of the following demonstrate good clinical decision making during intervention? (Select all that apply.)

• The nurse reviews the options for pain relief for the patient

• The nurse assesses whether the prn medication, ordered every 4 to 6 hours and last given 4 hours ago, is effective and whether a new type of medication is needed.

• The nurse reviews the policy and procedure for the cold application

• The nurse considers how the patient might react if the pain medication is held until an hour before physical therapy

• The nurse delegates vital sign assessment of the patient returning from surgery to the assistive personnel

A nurse working the evening shift has five patients and is teamed up with an assistive personnel. One of the assigned patients has just returned from surgery, one is newly admitted, and one has requested a pain medication. The patient who has returned from surgery just minutes ago has a large abdominal dressing, is still on oxygen by nasal cannula, and has an intravenous line. One of the other patients has just called out for assistance in setting up a meal tray. Another patient is stable and resting comfortably. Which patient is the nurse’s current greatest priority?

• Patient in pain

• Patient newly admitted

• Patient who returned from surgery

• Patient requesting assistance with meal tray

The nurse administers a tube feeding via a patient’s nasogastric tube. This is an example of which of the following?

• Physical care technique

• Activity of daily living

• Indirect care measure

• Lifesaving measure

Which principle is most important for a nurse to follow when using a clinical practice guideline for an assigned patient?

• Knowing the source of the guideline

• Reviewing the evidence used to develop the guideline

• Individualizing how to apply the clinical guideline for a patient

• Explaining to a patient the purpose of the guideline

A nurse is visiting a patient who lives alone at home. The nurse is assessing the patient’s adherence to medications. While talking with the family caregiver, the nurse learns that the patient has been missing doses. The nurse wants to perform interventions to improve the patient’s adherence. Which of the following will affect how this nurse will make clinical decisions about how to implement care for this patient? (Select all that apply.)

• Reviewing the family caregiver’s availability during medication administration times

• Determining the value the patient places on taking medications

• Reviewing the number of medications and time each is to be taken

• Determining all consequences associated with the patient missing specific medicines

• Reviewing the therapeutic actions of the medications

The nurse enters a patient’s room and finds that the patient was incontinent of liquid stool. Because the patient has recurrent redness in the perineal area, the nurse worries about the risk of the patient developing a pressure injury. The nurse cleanses the patient, inspects the skin, and applies a skin barrier ointment to the perineal area. The nurse consults the ostomy and wound care nurse specialist for recommended skin care measures. Which of the following correctly describe the nurse’s actions? (Select all that apply.)

• The application of the skin barrier is a dependent care measure.

• The call to the ostomy and wound care specialist is an indirect care measure

• The cleansing of the skin is a direct care measure.

• The application of the skin barrier is an instrumental activity of daily living

• Inspecting the skin is a direct care activity

Match the category of direct care on the too with the specific direct care activity on the bottom

1. Counseling ___

2. Lifesaving measure ____

3. Physical care technique ___

4. Activity of daily living ____

a. Assisting patient with oral care

b. Discussing a patient’s options in choosing palliative care

c. Protecting a violent patient from injury

d. Using safe patient handling during positioning of a patient

Which measures does a nurse follow when being asked to perform an unfamiliar procedure? (Select all that apply.)

• Checks scientific literature or policy and procedure

• Determines whether additional assistance is needed

• Collects all necessary equipment

• Delegates the procedure to a more experienced nurse

• Considers all possible consequences of the procedure

A nurse is conferring with another nurse about the care of a patient with a stage II pressure injury. The two decide to review the clinical practice guideline of the hospital for pressure injury care. The use of a clinical practice guideline achieves which of the following? (Select all that apply.)

• Allows nurses to act more quickly and appropriately

• Sets a level of clinical excellence for practice

• Eliminates need to create an individualized care plan for the patient

• Incorporates evidence-based interventions for stage II pressure injury

• Provides for access to patient care information within the electronic health record