The nurse is preparing to implement plans of care with several ...

[K@]

The nurse is preparing to implement plans of care with several clients. Which action would be inappropriate for the nurse to perform?
 
  A) Ask the English-as-a-Second-Language (ESOL) client to state in his or her own words what it means to be NPO.
  B) Seek input from the family of how the client with aphasia normally communicates at home.
  C) Respond to the postoperative client's question that baths are given only in the morning.
  D) Request that family members provide ethnic/cultural foods of the African client's liking.

Question 2

The nurse is delegating to the unlicensed assistive personnel (UAP). What is the best instruction by the nurse?
 
  A) Notify me right away if the client's systolic blood pressure is 170 or greater.
  B) Let me know if the client's blood pressure becomes elevated.
  C) If the client's blood pressure falls outside normal limits, come get me.
  D) I need to know if the client's blood pressure changes from his normal baseline.

[bobsmith]

Answer to Question 1

Ans: C

Guidelines for implementing indicate that the nurse implements care that is culturally sensitive and individualized for the client. The nurse forms a partnership with the client and family when implementing care. The response by the nurse indicating a set time for baths is not reflective of being open to individualizing client care. The other options are consistent with the guidelines for implementing.

Answer to Question 2

Ans: A

When delegating tasks, it is essential for the nurse to give clear instructions to the person to whom the task is being delegated. The statement, which includes specific parameters for the systolic blood pressure, clearly identifies what the UAP should be alerted to and the subsequent action to take. The other three options are vague and do not provide adequate direction for the UAP.

[K@]

TYSM

[vickybb89]

Excellent