Question 1

What is one advantage of having a standard classification of nursing interventions?&#10;A) to standardize nomenclature (names or terms)&#10;B) to legitimize the use of the nursing process&#10;C) to classify indicators of patient outcomes&#10;D) to facilitate documentation of expected goals

Accepted Answer

Having a standard classification of nursing interventions allows for standardized nomenclature, or names and terms, to be used across all healthcare settings. This helps to eliminate confusion and ensure clear communication among healthcare providers.

Question 2

What phrase best describes nurse-initiated interventions?&#10;A) nurse-prescribed interventions&#10;B) physician-prescribed interventions&#10;C) healthcare team interventions&#10;D) interventions based on medical orders

Accepted Answer

Nurse-initiated interventions are interventions that are prescribed by the nurse without the need for a physician's order. The nursing diagnosis guides the formulation of the plan of care, including the selection of nurse-prescribed interventions.

Question 3

Which of the following examples of nursing actions involve direct care of the patient? Select all that apply.&#10;A) A nurse counsels a young family who is interested in natural family planning.&#10;B) A nurse massages the back of a patient while performing a skin assessment.&#10;C) A nurse arranges for a consultation for a patient who has no health insurance.&#10;D) A nurse helps a patient in hospice fill out a living will form.&#10;E) A nurse arranges for physical therapy for a patient who had a stroke.&#10;F) A nurse comforts a distraught patient whose baby was stillborn.

Accepted Answer

A, B, D, E

Question 4

A nurse documents the following diagnosis for a hospitalized patient: Risk for Imbalanced Nutrition: More Than Body Requirements. What is the major goal of interventions for a risk diagnosis?&#10;A) reduce or eliminate contributing factors&#10;B) prevent the problem&#10;C) collect additional data&#10;D) promote higher-level wellness

Accepted Answer

The major goal of interventions for a risk diagnosis, such as "Risk for Imbalanced Nutrition: More Than Body Requirements," is to prevent the problem from occurring.

Question 5

What must occur before physician-initiated interventions can be carried out?&#10;A) They must be written on the nursing plan of care.&#10;B) The nurse relinquishes all responsibility for them.&#10;C) Any healthcare provider may order them.&#10;D) The physician gives a verbal or written order.

Accepted Answer

Physician-initiated interventions require a physician to give a verbal or written order, as they are ordered by the physician and not considered within the scope of nursing practice to initiate on their own. A and B are incorrect because interventions ordered by the physician do not have to be written on the nursing plan of care, and the nurse still maintains responsibility for carrying out the orders. C is incorrect because not all healthcare providers are authorized to give physician-initiated orders.

Question 6

A nurse is catheterizing a patient. What action illustrates respect for the patient's privacy?&#10;A) explaining the procedure to the family&#10;B) leaving the patient's pajamas on&#10;C) closing the door to the room&#10;D) asking another nurse if he wants to watch

Accepted Answer

Closing the door to the room ensures that the patient's privacy is respected and maintained during the catheterization procedure. It prevents anyone from accidentally entering the room and seeing the patient in a vulnerable state. Options A, B, and D do not demonstrate respect for the patient's privacy. Explaining the procedure to the family is important for the patient's informed consent but should be done before the catheterization and not in the patient's presence. Leaving the patient's pajamas on is not sufficient for maintaining privacy as the nurse will still need to expose the area around the urethra for catheter insertion. Asking another nurse if he wants to watch violates the patient's privacy and is inappropriate.

Question 7

According to the American Nurses Association, who determines the scope of nursing practice?&#10;A) nurses&#10;B) lawyers&#10;C) physicians&#10;D) consumers

Accepted Answer

According to the American Nurses Association, the scope of nursing practice is determined by nurses through their education, experience, and competence. It is based on the latest research evidence and is regulated by nursing boards in each state. While other healthcare professionals and consumers may provide input and feedback, the final determination of the scope of nursing practice is made by nurses themselves.

Question 8

What core value of nursing care is missing when a nursing intervention is delegated to a UAP?&#10;A) communication&#10;B) patient teaching&#10;C) nurse/patient dynamic&#10;D) competent care

Accepted Answer

Delegating a nursing intervention to an unlicensed assistive personnel (UAP) can disrupt the nurse/patient dynamic, as the direct interaction and relationship-building between the nurse and patient may be compromised.

Deck 11: Implementing