Author Question: The client is scheduled to receive Coumadin (an anticoagulant) at 9:00 AM. His morning labora-tory ... (Read 60 times)

burton19126 · **on:** Jul 23, 2018

The client is scheduled to receive Coumadin (an anticoagulant) at 9:00 AM. His morning labora-tory results show him to have a high partial thromboplastin time (PTT). His nurse decides to withhold the Coumadin. Which step of the implementation process is s

1. Reassessing the client
2. Stating an expected outcome
3. Revising the nursing diagnosis
4. Modifying the nursing care plan

Question 2

The nurse notes that a narcotic is to be administered per epidural cath. The nurse; however, does not know how to perform this procedure. Which aspect of the implementation process should be followed?

1. Seek assistance
2. Reassess the client
3. Use interpersonal skills
4. Critical decision making

Melissahxx · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

ANS: 4
The nurse is modifying the nursing care plan. Data have been updated to reflect the client's cur-rent status of an elevated PTT; nursing diagnoses and specific interventions are revised. In this case, the revised intervention is withholding the Coumadin. By gathering further assessment data and revising nursing interventions, the nurse is modifying the nursing care plan.

Answer to Question 2

ANS: 1
If a nurse does not know how to perform a procedure, he or she should seek assistance. Infor-mation about the procedure is obtained from the literature and the agency's procedure book. All equipment necessary for the procedure is collected. Finally, another nurse who has completed the procedure correctly and safely provides assistance and guidance. Reassessing the client is a par-tial assessment that may focus on one dimension of the client or on one system. Interpersonal skills are used to develop a trusting relationship, express a level of caring, and communicate clearly with the client, family, and health care team. Critical decision making is used when the nurse implements the care plan using the knowledge bases necessary for care planning and then completing the planned interventions most effectively.