Alexandra Bozan
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UNIT III: Person-Centered Care and the Nursing Process Chapter 14: Implementing

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Alexandra Bozan
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Chapter 14: Implementing

Question 1 of 33

1

A school nurse notices that a female adolescent student is losing weight and decides to perform a focused assessment of her nutritional status to determine if she has an eating disorder. How should the nurse proceed?

Select one of the following:

  • Perform the focused assessment. This is an independent nurse-initiated interventions.

  • Request an order from Jill's physician since this is a physician-initiated intervention

  • Request an order from Jill's physician since this is a collaborative intervention

  • Request an order from the nutritionist since this is a collaborative intervention

Explanation

Question 2 of 33

1

A nurse is using the implementation step of the nursing process to provide care for patients in a busy hospital setting. Which nursing actions best represent this step?

Select one or more of the following:

  • The nurse carefully removes the bandages form a burn victim's arm

  • The nurse assesses a patient to check nutritional status

  • The nurse formulates a nursing diagnosis for a patient with epilepsy

  • The nurse turns a patient's insurance coverage at the initial review

  • The nurse checks for community resources for a patient with dementia

Explanation

Question 3 of 33

1

Nurses use the Nursing Interventions Classification Taxoconomy structure as a resource when planning nursing care for patients. What information would be found in this structure?

Select one of the following:

  • Case studies illustrating a complete set of activities that a nurse performs to carry out nursing interventions

  • Nursing interventions each with a label, a definition, and a set of activities that a nurse performs to carry it out, with a short list of background listings

  • A complete list of nursing diagnosis, outcomes and related nursing activities for each nursing intervention

  • A complete list of reimbursable charges for each nursing intervention

Explanation

Question 4 of 33

1

A new RN is being oriented to a nursing unit that is currently understaffed and is told that the UAPs have been trained to obtain the initial assessment. What is the best response of the RN?

Select one of the following:

  • Allow the UAP to do the admission assessment and report the finding to the RN

  • Do his or her own admission assessments but don't interfere with the practice if other professional RNs seem comfortable with the practice

  • Tell the charge nurse that he or she chooses not to delegate the admission assessment until further clarification is received from administration

  • Contact his/her labor representative and complain about the practice

Explanation

Question 5 of 33

1

A nurse performs nurse-initiated nursing actions when caring for patients in a skilled nursing facility. Which are examples of these types of interventions?

Select one or more of the following:

  • A nurse administers 500 mg of ciprofloxacin to a patient w/pneumonia

  • A nurse consults with a psychiatrist for a patient who abuses pain killers

  • A nurse checks the skin of bedridden patients for skin breakdown

  • A nurse orders a kosher meal for an orthodox Jewish patient

  • A nurse records the I&O of a patient as prescribed by this physician

  • A nurse prepares a patient for minor surgery according to facility protocol

Explanation

Question 6 of 33

1

A nurse is about to perform pin site care for a patient who has a halo traction device installed. What is the first nursing action that should be taken prior to performing this care?

Select one of the following:

  • Administer pain medication

  • Reassess the patient

  • Prepare the equipment

  • Explain the procedure to the patient

Explanation

Question 7 of 33

1

A nurse develops a detailed plan of care for 16 year old female who is a new single mother of a premature infant. The plan includes collaborative care measures and home health care visits. When presented with the plan, the patient states "We will be fine on our own, I don't need any more care." What would be the nurse's best response?

Select one of the following:

  • You know your personal situation better than I do, so I will respect your wishes.

  • If you don't accept the services, your baby's health will suffer

  • Let's take a look at the plan again and see if we can adjust it to fit your needs

  • I'm going to assign your case to a social worker who can explain the services better

Explanation

Question 8 of 33

1

An RN working on a busy hospital unit delegates patient care to an UAP. Which patient care could the nurse delegate to UAP?

Select one or more of the following:

  • Performing the initial patient assessment

  • Making patient beds

  • Giving patient bed baths

  • Administering patient meds

  • Ambulating patients

  • Assisting patients w/meals

Explanation

Question 9 of 33

1

A student is organizing clinical responsibilities for an 84-year old female patient who is diabetic and is being treated for foot ulcers. The patient tells the student "I need to have my hair washed before I can do anything else today. I am ashamed of the way I look." The patient's need include diagnostic testing, dressing changes, meal planning,, counseling, and assistance with hygiene. How would the nurse best prioritize this patient's care?

Select one of the following:

  • Explain to the patient that there is not enough time to wash her hair today because of her busy schedule

  • Schedule the testing and meal planning first and complete hygiene as time permits

  • Perform the dressing changes first, scheduling the testing and counseling, and complete hygiene last

  • Arrange to wash the patient's hair first, perform hygiene, and schedule diagnostic testing/counseling

Explanation

Question 10 of 33

1

The nurse continues to collect data and to modify the plan of care as needed.

Select one of the following:

  • True
  • False

Explanation

Question 11 of 33

1

It is not important for the nurse to make rounds with other health care professionals and to read the results of consultations.

Select one of the following:

  • True
  • False

Explanation

Question 12 of 33

1

Nurses always monitor the patient's responses to the interventions.

Select one of the following:

  • True
  • False

Explanation

Question 13 of 33

1

Fill the blank spaces to complete the text.

It is critical to the patient carefully before initiating any to make sure that the plan of care is still responsive to the patient's and prioritized to the most pressing of those .

Explanation

Question 14 of 33

1

Fill the blank spaces to complete the text.

Order at the beginning of the shift for the care you expect to provide, and be thoughtful of the nurse who will follow you by leaving adequate supplies.

Explanation

Question 15 of 33

1

Fill the blank spaces to complete the text.

In patient encounter, an important nursing intervention is ongoing .

Explanation

Question 16 of 33

1

Fill the blank spaces to complete the text.

Another vital nursing intervention, is ongoing .

Explanation

Question 17 of 33

1

Fill the blank spaces to complete the text.

While monitoring the patient's responses to the plan of care, nurses are also alert to the development of new that may result in the identification of new or .

Explanation

Question 18 of 33

1

Fill the blank space to complete the text.

When a patient does not follow the plan of care despite your best efforts, it is time to the strategy.

Explanation

Question 19 of 33

1

Which nursing actions reflect the implementing step of nursing process?

Select one or more of the following:

  • Referring the client to community resources, when necessary

  • Determining the client's response to nursing interventions

  • Selecting culturally sensitive interventions

  • Using evidence-based interventions individualized for the client

  • Providing education to lower health risks

Explanation

Question 20 of 33

1

Which of the following nursing interventions is most likely to be allowed w/in the parameters of a protocol or standing order?

Select one of the following:

  • Administering a glycerin suppository to a constipated client who has not responded to oral stool softeners

  • Changing a client's IV fluid from normal saline to 5% dextrose

  • Changing a client's advance directive after his prognosis has significantly worsened

  • Administering a beta-adrenergic blocker to a new client whose blood pressure is high on admission assessment

Explanation

Question 21 of 33

1

Which of the following is a nursing intervention that facilitates life span care?

Select one of the following:

  • teach contraceptive options for planned pregnancy

  • explore factors that could motivate adolescents members of the family to engage in risky behavior

  • identify coping strategies for the family that have worked in the past

  • educate family members about normal growth and development patterns

Explanation

Question 22 of 33

1

Which is the responsibility of the nurse in the nurse-health care team relationship?

Select one or more of the following:

  • Serve a liaison between the client/family/health care team

  • Provide creative leadership to make the nursing unit a satisfying and challenging place to work

  • Coordinate the inputs of the multidisciplinary team into into a comprehensive plan of care

  • Educate the family to be informed and assertive consumers of health care

  • Support the nursing care given by other nursing personnel

Explanation

Question 23 of 33

1

The nurse ascertains that the client is failing to follow the plan that was collaboratively developed. Further investigation determines that the plan of care is not appropriate for this client. What is the nurse's next step in correcting the problem?

Select one of the following:

  • Making changes in the plan of care based upon assessment data

  • Asking the client's family to assist the client in following the care plan

  • Providing information to the client on the benefits of complying w/the plan of care

  • Discussing desired outcomes w/the client and the importance of the outcomes

Explanation

Question 24 of 33

1

A nurse is preparing to educate a client about self-care after a cataract surgery. Which of the following would the nurse do first?

Select one of the following:

  • Ensure physician approval for the education plan

  • Determine the client's willingness to follow the regimen

  • Identify changes from the baseline

  • Instruct the nursing assistant on what to teach the client

Explanation

Question 25 of 33

1

A nurse on duty finds that a client is anxious about the results of laboratory testing. Which intervention by the nurse reflects a supportive intervention?

Select one of the following:

  • Telling the laboratory technician to speed up the results

  • Calling the physician for an order for an anxiolytic

  • Educating the client about reducing risk factors

  • Sitting with the client to encourage her to talk

Explanation

Question 26 of 33

1

Which are essential components for delegating nursing care?

Select one or more of the following:

  • The UAP can verbalize what information is to be reported to the nurse.

  • The UAP evaluates the client's response after implementing the task, then reports to the nurse

  • The task is delegated to the person with sufficient knowledge

  • The nurse seeks input from the UAP in planning the client's care for the shift

  • Instructions have been clearly communicated by the nurse to the UAP

Explanation

Question 27 of 33

1

Which nursing intervention is appropriate for a risk nursing diagnoses?

Select one or more of the following:

  • Monitor the client's status

  • Prevent the problem

  • Reduce or eliminate risk factors

  • Collect additional data to rule out the diagnosis

  • Promote higher level wellness

Explanation

Question 28 of 33

1

After learning about a client's limited financial resources and limited insurance benefits, the home care nurse modifies nursing interventions related to a client's care instructions. The nurse modifies the plan of care based upon which client variable?

Select one of the following:

  • Current standards of care

  • Research findings

  • Psychosocial background

  • Developmental stage

Explanation

Question 29 of 33

1

The nurse is caring for a postoperative client who is receiving morphine sulfate for pain management. The nurse obtains the following vital signs. HR 74 RR 8 BP 114/68. After reviewing the nursing care plan and physician orders, the nurse administers naloxone (Narcan). What would allow the nurse to initiate this action?

Select one of the following:

  • Algorithm

  • Order set

  • Standing orders

  • Protocol

Explanation

Question 30 of 33

1

The nurse is preparing to administer oxygen 3 Liters/minute via nasal cannula. The nursing student asks "What type of intervention is oxygen administration? What is the best response by the nurse?

Select one of the following:

  • Oxygen administration is an independent nursing intervention, because nurses have the necessary skill to administer oxygen

  • Oxygen administration is a dependent nursing intervention because oxygen is considered a drug that requires a physician's order

  • Oxygen administration is a collaborative nursing intervention, because it is ordered by the respiratory therapist

  • Oxygen administration is an interdependent intervention because physicians, nurses, and respiratory therapist have the necessary skills to administer oxygen

Explanation

Question 31 of 33

1

A student nurse is performing a sterile dressing change on a client's abdominal incision. While establishing her sterile field, she drops the forceps on the floor. She is unable to continue with the dressing change because she has no extra supplies, and no one is present to bring new forceps. The student has failed to organize

Select one of the following:

  • equipment and personnel

  • skills and assistance

  • logistics and planning

  • environment and client

Explanation

Question 32 of 33

1

Which of the following examples of nursing actions involve direct care of the client?

Select one or more of the following:

  • A nurse arranges for a consultation for a client that has no health insurance

  • A nurse massages the back of a client while performing a skin assessment

  • A nurse helps a client in hospice fill out a living will form

  • A nurse arranges for physical therapy for a client who had a stroke

  • A nurse counsels a young family who is interested in natural family planning

Explanation

Question 33 of 33

1

The nurse is attending a conference on evidence based practice. Which statement by the nurse indicates further education is needed?

Select one of the following:

  • Nursing interventions should be supported by a sound scientific rationale

  • I can learn about evidence based practice by reading professional journals

  • I must conduct research to validate the unsefulness of my nursing interventions

  • The Agency for Healthcare Research and Quality is a resource for evidence based practice

Explanation

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