Deck 6: Planning Interventions

Question 1

The nurse completes the plan of care for a patient with a medical diagnosis of Gall Bladder Disease. Which consideration will the nurse use when selecting nursing interventions to best help the patient achieve desired outcomes? Select all that apply.
1)Age of the patient
2)Patient abilities and preferences
3)Education levels of the nursing staff
4)Medical orders
5)General health status

Answer 1

1, 2, 3, 4, 5

Question 2

The nurse is developing a plan of care for a client at an adult wellness clinic. Which primary decision maker does the nurse recognize when caring for healthy adult clients?
1)Provider
2)Family
3)Client
4)Nurse

Answer 2

3

Question 3

A client newly diagnosed with diabetes mellitus is admitted to the hospital because of poorly controlled glucose levels. Which action by the nurse is an appropriate direct-care intervention for this client during the client's hospitalization?
1)Consulting the diabetic nurse educator for help with a teaching plan
2)Making arrangements for the client to join a diabetic support group
3)Demonstrating blood glucose monitoring and insulin administration to the client
4)Consulting with the dietician about the client's dietary concerns

Answer 3

3

Question 4

The quality assurance team is reviewing nursing documentation for quality and correctness. Which is the best example of a well-written nursing order?
1)Administer pain medication 30 minutes prior to physical therapy exercises.
2)Teach patient how to self-administer insulin injections prior to discharge.
3)The nurse will assess vital signs and report changes, as needed.
4)Consider patient and family cultural preferences in diet order.

Question 5

The nurse works in an acute healthcare facility on a unit where patients with chronic health problems frequently return for treatment and management. The nurses are expected to use evidence-based practice (EBP) for the determination of best care. Which action by a nurse reflects understanding about EBP?
1)The nurse submits compiled research to nursing administration.
2)The nurse conducts a systematic review of published research.
3)The nurse informs the patient care is based on research evidence.
4)The nurse only uses research that reflects the patient's condition.

Question 6

The nurse recognizes which statement(s) about nursing interventions as being true? Select all that apply.
1)Writing of nursing orders cannot be delegated to the licensed practical nurse/licensed vocational nurse (LPN/LVN).
2)The best nursing interventions are based on traditional care.
3)Nursing interventions are individualized and culturally sensitive.
4)Standardized nursing interventions improve care for a specific client.
5)Evidence-based practice (EBP) must always be used for nursing interventions.

Question 7

The nurse is completing a plan of care for a patient with congestive heart failure. Which direct-care nursing intervention does the nurse perform?
1)Collaborate with the physician for further medication orders.
2)Instruct the patient about low-sodium and low-fat diets.
3)Refer the patient to cardiac rehabilitation for a home-care program.
4)Consult with physical therapist for cardiac rehabilitation exercises.

Question 8

The nurse is aware of which descriptions being best related to the primary goal(s) of evidence-based practice (EBP)? Select all that apply.
1)Presents the most effective treatments
2)Identifies the most cost-effective treatments
3)Includes all patient and family preferences
4)Creates standardized facility clinical pathways
5)Adds more studies to support an intervention

Question 9

The nurse is performing preoperative teaching for a client who is scheduled for surgery in the morning. The client does not at present have any respiratory problems. The nurse's teaching plan includes coughing and deep-breathing exercises. Which type of nursing intervention is the nurse performing?
1)Health promotion
2)Treatment
3)Prevention
4)Assessment

Question 10

The nurse is providing care for an adult smoker hospitalized on a medical-surgical unit. The patient states, "I'd really like some help in quitting smoking." As part of the nurse's intervention plan, a smoking cessation class is included. Which type of intervention is the nurse performing?
1)Wellness
2)Prevention
3)Assessment
4)Treatment

Question 11

A client is admitted to the hospital with an acute respiratory problem resulting from lung disease. The nurse makes a diagnosis of Ineffective Breathing Pattern related to inability to maintain adequate rate and depth of respirations. Which nursing intervention should be listed first on the care plan?
1)Determine airway adequacy hourly and as needed.
2)Administer prescribed oxygen therapy, as needed.
3)Monitor and report arterial blood gas values.
4)Place the client in the high Fowler's position.

Question 12

A client is admitted to the hospital with an acute episode of chronic obstructive pulmonary (lung) disease. The nurse makes a diagnosis of Ineffective Breathing Pattern related to inability to maintain adequate rate and depth of respirations and has recorded the diagnosis and appropriate goals on the care plan. When selecting nursing interventions, which nursing action does the nurse do first?
1)Identify several interventions likely to achieve the desired outcomes.
2)Review the problem and etiology of the nursing diagnosis.
3)Choose the best interventions for the patient.
4)Review the goals written by the nurse.

Question 13

Which is the best example of a well-written nursing order?
1)Provide emotional support to patient and family, as needed.
2)Assist with performance of personal hygiene, if necessary.
3)Follow prescribed fluid restriction of 1,500 mL per day.
4)Insert urinary catheter if patient has not voided within 8 hours.

Question 14

A nurse makes a nursing diagnosis of Acute Pain related to the postoperative abdominal incision. The nurse writes a nursing order to reposition the client in a comfortable position by using pillows to splint or support the painful areas. Which type of nursing intervention did the nurse write?
1)Collaborative
2)Interdependent
3)Dependent
4)Independent

Question 15

The nurse works in an acute care setting as a patient educator for patients newly diagnosed with diabetes mellitus. Which nursing intervention by this nurse is an indirect-care intervention?
1)Providing emotional support to patients
2)Conducting classes for teaching diet management
3)Requesting classroom furniture for adult patients
4)Recommending medical care for diabetic ulcers

Question 16

The nurse is selecting nursing interventions for a patient with diabetes mellitus. Which available resources does the nurse use to assist in the selection of interventions? Select all that apply.
1)A computer-generated list of standardized interventions
2)Self-generated interventions based on knowledge and experience
3)Traditional interventions that seem to have worked in the past
4)Only those interventions that agree with patient preferences
5)Suggested interventions from the facility policy and procedures

Question 17

An adult patient returns to the medical-surgical unit after undergoing abdominal surgery for colon cancer. Which is an appropriate, correctly written nursing order for this patient?
1)(Date) Encourage use of the incentive spirometer every hour while the client is awake. (Nurse's Signature)
2)(Date) Uses incentive spirometer 10 times every hour while awake to 1,000 mL. (Nurse's Signature)
3)(Date) Incentive spirometer hourly while awake.
4)Offer incentive spirometer to the client.

Question 18

The nurse is gathering data on a patient who is admitted. During the admission process, the nurse notices constant throat clearing behaviors by the patient. Which intervention does the nurse implement if viewing the patient's behavior from a physiological viewpoint?
1)Ask the patient to explain the noted behavior.
2)Seek a prescription for a bedside humidifier.
3)Administer prescribed pain medication.
4)Inquire about the patient's anxiety level.

Question 19

The nurse finishes developing the nursing interventions for a patient. Which questions does the nurse ask mentally after the development and before the implementation of nursing interventions? Select all that apply.
1)Do I possess the skills and knowledge to carry out the interventions?
2)Will any of the interventions interfere with medical prescriptions?
3)Have I explained the intervention enough to obtain patient support?
4)Does administration support expenses associated with the intervention?
5)What consequences might occur from performance of this intervention?

Question 20

The nurse is using electronic care planning. The nurse enters the patient's nursing diagnosis into the computer, selects desired outcomes, and validates the patient data, diagnosis, and goals. When considering the list of program generated interventions, the nurse identifies none of them fits this patient's individual needs. Which action does the nurse take?
1)Reject them all, and enter self-generated appropriate interventions.
2)Select the most suitable interventions from the program.
3)Ask another nurse to assess the patient, and give a recommendation.
4)Restart the computer to eliminate the possibility of a program malfunction.