When initiating the implementation phase of the nursing process, the nurse performs which of the following phases first?
Answer
Carrying out nursing interventions
Determining the need for assistance
Reassessing the client
Documenting interventions
Question 2
Question
Under what circumstances is it considered acceptable practice for the nurse to document a nursing activity before it is carried out?
Answer
When the activity is routine (e.g., raising the bed rails)
When the activity occurs at regular intervals (e.g., turning the client in bed)
When the activity is to be carried out immediately (e.g., a stat medication)
It is never acceptable
Question 3
Question
The primary purpose of the evaluating phase of the care planning process is to determine whether
Answer
Desired outcomes have been met.
Nursing activities were carried out.
Nursing activities were effective
Client’s condition has changed.
Question 4
Question
The client has a high-priority nursing diagnosis of Risk for Impaired Skin Integrity related to the need for several weeks of imposed bed rest. The nurse evaluates the client after 1 week and finds the skin integrity is not impaired. When the care plan is reviewed, the nurse should perform which of the following?
Answer
Delete the diagnosis since the problem has not occurred.
Keep the diagnosis since the risk factors are still present
Modify the nursing diagnosis to Impaired Mobility.
Demote the nursing diagnosis to a lower priority.
Question 5
Question
If the nurse planned to evaluate the length of time clients
must wait for a nurse to respond to a client need reported
over the intercom system on each shift, which process does
this reflect?
Answer
Structure evaluation
Process evaluation
Outcome evaluation
Audit
Question 6
Question
Which of the following is true regarding the relationship of implementing to the other phases of the nursing process?
Answer
The findings from the assessing phase are reconfirmed in the implementing phase.
After implementing, the nurse moves to the diagnosing phase.
The nurse’s need for involvement of other health care team members in implementing occurs during the planning phase.
Once all interventions have been completed, evaluating can begin.
Question 7
Question
The care plan calls for administration of a medication plus client education on diet and exercise for high blood pressure. The nurse finds the blood pressure extremely elevated. The client is very distressed with this finding. Which nursing skill of implementing would be needed most?
Answer
Cognitive
Intellectual
Interpersonal
Psychomotor
Question 8
Question
Which of the following demonstrates appropriate use of guidelines in implementing nursing interventions? Select all that apply.
Answer
No interventions should be carried out without the nurse having clear rationales.
Always follow the primary care provider’s orders exactly, without variation.
Encourage all clients to be as dependent as desired and allow the nurse to perform care for them.
When possible, give the client options in how interventions will be implemented.
Each intervention should be accompanied by client teaching.
Question 9
Question
Which of the following represents application of the components of evaluating?
Answer
Goal achievement must be written as either completely met or unmet.
Data related to expected outcomes must be collected.
If the outcome was achieved, conclude that the plan was effective.
After determining that the outcome was not met, start over with a new nursing care plan.
Question 10
Question
An element of quality improvement, rather than quality assurance, is which of the following?