A nurse is assisting with the plan of care for a client. Which of the following activities should the nurse include in the implementation phase of the nursing process?

Establishing the priorities of client care

Reinforcing teaching about the client's diagnosis

Asking the client about the presence of pain

Comparing the client's current laboratory values to previous results

Answer and Explanation

The Correct Answer is B

A) Establishing the priorities of client care:

Establishing priorities of client care typically occurs during the planning phase of the nursing process, not during implementation. During the planning phase, the nurse identifies the most urgent client needs based on assessments and formulates a plan of action to address those needs.

B) Reinforcing teaching about the client's diagnosis:

Reinforcing teaching about the client's diagnosis is an appropriate activity during the implementation phase of the nursing process. Implementation involves carrying out the planned interventions, which may include educating the client about their diagnosis, treatment plan, and self-care strategies. Reinforcing teaching ensures that the client understands their condition and how to manage it effectively.

C) Asking the client about the presence of pain:

Assessing the client for pain is typically part of the assessment phase of the nursing process, not the implementation phase. During assessment, the nurse gathers data about the client's pain experience, including location, intensity, quality, and factors that alleviate or exacerbate pain.

D) Comparing the client's current laboratory values to previous results:

Comparing laboratory values is a component of data interpretation and analysis, which occurs primarily during the evaluation phase of the nursing process. While the nurse may review laboratory values during implementation to monitor the client's response to interventions, comparing current values to previous results is more closely associated with evaluating the effectiveness of care provided.

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Correct Answer is C

Explanation

A) The surgeon should delay surgery until he can obtain informed consent from a parent:

This option is not feasible in emergencies where immediate surgical intervention is required to save the client's life or prevent further harm. Delaying surgery could jeopardize the client's health and violate the principle of beneficence, which prioritizes the client's well-being.

B) The client's pediatrician can obtain implied consent:

While pediatricians often play a role in providing medical care to minors, implied consent typically pertains to emergency situations where immediate intervention is necessary, and obtaining consent from a parent or legal guardian is not possible. In this scenario, the surgeon, rather than the pediatrician, would be responsible for obtaining consent.

C) The surgeon can proceed with the surgery by invoking implied consent:

In emergency situations where immediate surgical intervention is required to prevent harm or save a client's life, healthcare providers may proceed with treatment under the doctrine of implied consent. Implied consent assumes that a reasonable person would consent to necessary medical treatment if they were able to do so. However, the specific legal requirements for invoking implied consent may vary depending on jurisdiction and institutional policies.

D) The surgeon can obtain informed consent from the client's adult cousin:

While obtaining consent from a close family member may be necessary in certain situations, such as when a parent is unavailable, it may not be legally sufficient in emergency situations where immediate action is required. Additionally, the legal authority to provide consent may vary depending on the jurisdiction and the client's age. In this scenario, relying on informed consent from the client's adult cousin could delay necessary surgical intervention and may not be appropriate without further legal clarification.

A. Ask the provider to give consent for the transfusion. B. Discuss taking guardianship of the client with the facility administration. C. Respect the daughter's decision to refuse the transfusion. D. Encourage the daughter to let her mother have the transfusion.

Correct Answer is C

Explanation

A) Ask the provider to give consent for the transfusion:

The provider cannot override the decision made by the client's designated healthcare proxy. Even if the provider were to give consent for the transfusion, it would not be ethically or legally appropriate to proceed with the treatment against the expressed wishes of the client's healthcare proxy.

B) Discuss taking guardianship of the client with the facility administration:

Seeking guardianship of the client would be an extreme measure and may not be necessary or appropriate in this situation. Guardianship is typically pursued when there are concerns about an individual's capacity to make decisions for themselves and when there is no designated healthcare proxy available to make decisions on their behalf. In this case, the client has a designated healthcare proxy, and it is more appropriate to respect the daughter's decision as the client's authorized representative.

C) Respect the daughter's decision to refuse the transfusion:

In situations where a client has designated a durable power of attorney for healthcare, the individual designated as the healthcare proxy has the legal authority to make healthcare decisions on behalf of the client, including the refusal of treatment. In this case, the daughter, acting as the client's healthcare proxy, has refused the blood transfusion for her mother. It is important for the nurse to respect and honor the daughter's decision, as it aligns with the client's previously documented wishes.

D) Encourage the daughter to let her mother have the transfusion:

While it is understandable that the nurse may want to advocate for the client's well-being, in this situation, the daughter's decision as the client's healthcare proxy must be respected. Encouraging the daughter to change her decision would not be appropriate if it goes against her understanding of what is in her mother's best interests and the client's previously documented wishes.

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A nurse is assisting with the plan of care for a client. Which of the following activities should the nurse include in the implementation phase of the nursing process?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a 16-year-old client who was in a motor-vehicle crash and needs surgical intervention immediately. The staff cannot reach either of the client's parents. The nurse should identify that which of the following is true about obtaining consent?

Correct Answer is C

Explanation

A nurse is caring for an older adult client who has advanced dementia and needs a blood transfusion. The client previously designated her adult daughter on a durable power of attorney for health care form, and the daughter refuses the treatment. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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