A nurse is documenting client care. Which of the following entries should the nurse identify as an example of implementation of client care?

"Contacted the provider to report client findings."

"Reports stomach pain as 3 on a pain scale of 0 to 10."

"Vomited 120 mL of clear, yellow emesis."

"Denies further nausea or vomiting since antiemetic administration.

Answer and Explanation

The Correct Answer is D

A. "Contacted the provider to report client findings." – This is an example of collaboration or communication, not direct implementation of care.

B. "Reports stomach pain as 3 on a pain scale of 0 to 10." – This is assessment, not implementation.

C. "Vomited 120 mL of clear, yellow emesis." – This is also assessment (objective data collection).

D. "Denies further nausea or vomiting since antiemetic administration." – This is implementation, as it evaluates the effect of an intervention (antiemetic administration).

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Correct Answer is A

Explanation

A. Ask the client to describe their feelings. Encouraging the client to express their emotions allows the nurse to assess their concerns and provide appropriate support. This is a key principle of therapeutic communication.

B. Discuss the competency of the surgeon with the client. While the surgeon's competency may help reassure the client, the nurse should not comment on the surgeon’s skill. Instead, the nurse should focus on the client's emotions and provide factual information about the procedure if needed.

C. Inform the client that others have had the procedure without problems. This response dismisses the client’s concerns rather than addressing their feelings. Each client’s experience is unique, and reassurance should be based on listening and providing accurate information.

D. Ask the client why they are experiencing anxiety. Asking “why” can make the client feel defensive. Instead, the nurse should use open-ended questions, such as "Can you tell me more about your concerns?", which encourages discussion without judgment.

A. Smoking B. Alcohol consumption C. Inflammatory bowel disease D. High-fat diet E. Colorectal polyps

Correct Answer is ["A","B","D"]

Explanation

A. Smoking – Smoking increases the risk of colorectal cancer and can be changed.

B. Alcohol consumption – Alcohol use increases cancer risk and is modifiable.

C. Inflammatory bowel disease – This is a non-modifiable risk factor.

D. High-fat diet – Dietary habits can be changed to lower the risk.

E. Colorectal polyps – Polyps are a non-modifiable risk factor.

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A nurse is documenting client care. Which of the following entries should the nurse identify as an example of implementation of client care?

Nursing Test Bank

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A nurse is documenting client care. Which of the following entries should the nurse identify as an example of implementation of client care?