Deck 19: Implementing Nursing Care

Question 1

Which action should the nurse take first during the initial phase of implementation?

A) Determine patient outcomes and goals.
B) Prioritize patient's nursing diagnoses.
C) Evaluate interventions.
D) Reassess the patient.

Answer 1

Reassess the patient.

Question 2

A newly admitted patient who is morbidly obese asks the nurse for assistance to the bathroom for the first time. Which action should the nurse take initially?

A) Ask for at least two other assistive personnel to come to the room.
B) Medicate the patient to alleviate discomfort while ambulating.
C) Review the patient's activity orders.
D) Offer the patient a walker.

Answer 2

Review the patient's activity orders.

Question 3

The standing orders for a patient include acetaminophen 650 mg every 4 hours prn for headache. After assessing the patient, the nurse identifies the need for headache relief and determines that the patient has not had acetaminophen in the past 4 hours. Which action will the nurse take next?

A) Administer the acetaminophen.
B) Notify the health care provider to obtain a verbal order.
C) Direct the nursing assistive personnel to give the acetaminophen.
D) Perform a pain assessment only after administering the acetaminophen.

Answer 3

Administer the acetaminophen.

Question 4

The nurse is revising the care plan. In which order will the nurse perform the tasks, beginning with the first step?
1) Revise specific interventions.
2) Revise the assessment column.
3) Choose the evaluation method.
4) Delete irrelevant nursing diagnoses.

A) 2, 4, 1, 3
B) 4, 2, 1, 3
C) 3, 4, 2, 1
D) 4, 2, 3, 1

Question 5

The nurse is teaching a new nurse about protocols. Which information from the new nurse indicates a correct understanding of the teaching?

A) Protocols are guidelines to follow that replace the nursing care plan.
B) Protocols assist the clinician in making decisions and choosing interventions for specific health care problems or conditions.
C) Protocols are policies designating each nurse's duty according to standards of care and a code of ethics.
D) Protocols are prescriptive order forms that help individualize the plan of care.

Question 6

The nurse inserts an intravenous (IV) catheter using the correct technique and following the recommended steps according to standards of care and hospital policy. Which type of implementation skill is the nurse using?

A) Cognitive
B) Interpersonal
C) Psychomotor
D) Judgmental

Question 7

A nurse is providing nursing care to patients after completing a care plan from nursing diagnoses. In which step of the nursing process is the nurse?

A) Assessment
B) Planning
C) Implementation
D) Evaluation

Question 8

Vital signs for a patient reveal a high blood pressure of 187/100. Orders state to notify the health care provider for diastolic blood pressure greater than 90. What is the nurse's first action?

A) Follow the clinical protocol for a stroke.
B) Review the most recent lab results for the patient's potassium level.
C) Assess the patient for other symptoms or problems, and then notify the health care provider.
D) Administer an antihypertensive medication from the stock supply, and then notify the health care provider.

Question 9

A patient recovering from a leg fracture after a fall reports having dull pain in the affected leg and rates it as a 7 on a 0 to 10 scale. The patient is not able to walk around in the room with crutches because of leg discomfort. Which nursing intervention is priority?

A) Assist the patient to walk in the room with crutches.
B) Obtain a walker for the patient.
C) Consult physical therapy.
D) Administer pain medication.

Question 10

The nurse is caring for a patient who requires a complex dressing change. While in the patient's room, the nurse decides to change the dressing. Which action will the nurse take just before changing the dressing?

A) Gathers and organizes needed supplies
B) Decides on goals and outcomes for the patient
C) Assesses the patient's readiness for the procedure
D) Calls for assistance from another nursing staff member

Question 11

Which initial intervention is most appropriate for a patient who has a new onset of chest pain?

A) Reassess the patient.
B) Notify the health care provider.
C) Administer a prn medication for pain.
D) Call radiology for a portable chest x-ray.

Question 12

A staff development nurse is providing an inservice for other nurses to educate them about the Nursing Interventions Classification (NIC) system. During the inservice, which statement made by one of the nurses in the room requires the staff development nurse to clarify the information provided?

A) "This system can help medical students determine the cost of the care they provide to patients."
B) "If the nursing department uses this system, communication among nurses who work throughout the hospital may be enhanced."
C) "We could use this system to help organize orientation for new nursing employees because we can better explain the nursing interventions we use most frequently on our unit."
D) "The NIC system provides one way to improve safe and effective documentation in the hospital's electronic health record."

Question 13

A nurse is reviewing a patient's care plan. Which information will the nurse identify as a nursing intervention?

A) The patient will ambulate in the hallway twice this shift using crutches correctly.
B) Impaired physical mobility related to inability to bear weight on right leg.
C) Provide assistance while the patient walks in the hallway twice this shift with crutches.
D) The patient is unable to bear weight on right lower extremity.

Question 14

The nurse establishes trust and talks with a school-aged patient before administering an injection. Which type of implementation skill is the nurse using?

A) Cognitive
B) Interpersonal
C) Psychomotor
D) Judgmental

Question 15

Which action indicates a nurse is using critical thinking for implementation of nursing care to patients?

A) Determines whether an intervention is correct and appropriate for the given situation
B) Reads over the steps and performs a procedure despite lack of clinical competency
C) Establishes goals for a particular patient without assessment
D) Evaluates the effectiveness of interventions

Question 16

A patient visiting with family members in the waiting area tells the nurse "I don't feel good, especially in the stomach." What should the nurse do?

A) Request that the family leave, so the patient can rest.
B) Ask the patient to return to the room, so the nurse can inspect the abdomen.
C) Ask the patient when the last bowel movement was and to lie down on the sofa.
D) Tell the patient that the dinner tray will be ready in 15 minutes and that may help the stomach feel better.

Question 17

A nurse is making initial rounds on patients. Which intervention for a patient with poor wound healing should the nurse perform first?

A) Reinforce the wound dressing as needed with 4 * 4 gauze.
B) Perform the ordered dressing change twice daily.
C) Observe wound appearance and edges.
D) Document wound characteristics.

Question 18

A new nurse is working in a unit that uses interdisciplinary collaboration. Which action will the nurse take?

A) Act as a leader of the health care team.
B) Develop good communication skills.
C) Work solely with nurses.
D) Avoid conflict.

Question 19

The nurse is intervening for a family member with role strain. Which direct care nursing intervention is most appropriate?

A) Assisting with activities of daily living
B) Counseling about respite care options
C) Teaching range-of-motion exercises
D) Consulting with a social worker

Question 20

The nurse is intervening for a patient that has a risk for a urinary infection. Which direct care nursing intervention is most appropriate?

A) Teaches proper handwashing technique
B) Properly cleans the patient's toilet
C) Transports urine specimen to the lab
D) Informs the oncoming nurse during hand-off

Question 21

A nurse is providing nursing care to a group of patients. Which actions are direct care interventions? (Select all that apply.)

A) Ambulating a patient
B) Inserting a feeding tube
C) Performing resuscitation
D) Documenting wound care
E) Teaching about medications

Question 22

A nurse is preparing to carry out interventions. Which resources will the nurse make sure are available? (Select all that apply.)

A) Equipment
B) Safe environment
C) Confidence
D) Assistive personnel
E) Creativity

Question 23

A nurse is implementing interventions for a group of patients. Which actions are nursing interventions? (Select all that apply.)

A) Order chest x-ray for suspected arm fracture.
B) Prescribe antibiotics for a wound infection.
C) Reposition a patient who is on bed rest.
D) Teach a patient preoperative exercises.
E) Transfer a patient to another hospital unit.

Question 24

Which interventions are appropriate for a patient with diabetes and poor wound healing? (Select all that apply.)

A) Perform dressing changes twice a day as ordered.
B) Teach the patient about signs and symptoms of infection.
C) Instruct the family about how to perform dressing changes.
D) Gently refocus patient from discussing body image changes.
E) Administer medications to control the patient's blood sugar as ordered.