Deck 19: Implementing Nursing Care

Question 1

Which of the following interventions is the best example of an indirect intervention directed towards client safety?
1) Checking on a restrained client every 15 minutes
2) Performing hand hygiene between client contacts
3) Including the diagnosis at risk for injury related to falls to a client's care plan
4) Turning on a night light to illuminate the path to the bathroom

Answer 1

4
Indirect care interventions are treatments performed away from the client but on behalf of the client or group of clients.For example,indirect care measures include actions for managing the client's environment (e.g. ,safety and infection control),documentation,and interdisciplinary collaboration.Directly impacting the light level in a client's room to minimize the risk for falls is the best example of a safety-oriented indirect care intervention.Including a nursing diagnosis regarding falls would also be an example of an indirect care intervention but it is not as actively affecting the client's safety.Checking a restrained client is a direct care intervention because it involves actual client contact,while performing hand hygiene is directed more towards infection control than safety.

Question 2

The client is given an injection of an antibiotic.Shortly afterwards the client reports hives and itching.The nurse administers an antihistamine to counteract the effect of the antibiotic.The nurse is using which one of the following intervention methods?
1) Preventive measures
2) Assisting with ADLs
3) Preparing for special procedures
4) Compensation for adverse reactions

Answer 2

4
Nursing actions that control for adverse reactions reduce or counteract the reaction,such as administering an antihistamine after an allergic reaction to a medication.Preventive measures promote health and prevent illness while assisting with ADLs and preparing for special procedures are direct care measures.

Question 3

An enterostomal nurse shows a client's significant other how to assist with the supplies for the ostomy and how to manipulate the ostomy equipment.In demonstrating this technique to the client's significant other,the nurse is using what type of nursing skill?
1) Affective
2) Cognitive
3) Interactive
4) Psychomotor

Answer 3

4
Psychomotor skills involve the integration of cognitive and motor activities,such as in providing ostomy care.Cognitive skills involve the application of nursing knowledge.Knowing the rationale for therapeutic interventions,understanding normal and abnormal physiological and psychological responses,and being able to identify client learning and discharge needs all require cognitive skills.Interpersonal skills are used when the nurse interacts with clients,their families,and other health care team members.Effective communication is an example of an interpersonal skill.Affective means pertaining to an emotion or mental state.

Question 4

The nurse is working with postoperative clients on a surgical unit.One aspect of care is manipulation of the client's environment.This involves the nurse:
1) Repositioning the client q2h
2) Removing clutter from the client's room
3) Delegating ambulation of clients to the nursing assistant
4) Providing pain medication to the client before a dressing change

Question 5

The fundamental goal for the development of a protocol for care of a client who has had a myocardial infarction client is to:
1) Implement care that has its basis in evidence-based practice
2) Produce care plans that are specific to the individual client needs
3) Improve the standard of care provided to the clients cared for on that unit
4) Provide the staff on that unit with guidelines to ensure the delivery of quality care

Question 6

An example of a cognitive nursing skill is:
1) Providing a soothing bed bath
2) Communicating with the client and family
3) Giving an injection to the client per the physician's orders
4) Recognizing the potential complications of a blood transfusion

Question 7

A client reports to the nurse that the room is "too hot." Which of the following nursing actions best reflects the nurse's understanding of the therapeutic manipulation of the client's environment?
1) Bringing a portable fan into the room
2) Assisting the client in the removal of excess clothing
3) Offering to ambulate the client into the visiting lounge
4) Closing the blinds to minimize the sunshine through the windows

Question 8

Which of the following statements best reflects the nurse's understanding of the function of client reassessment?
1) "The client's blood pressure is lower this morning than it was yesterday morning."
2) "30 minutes after receiving his pain medication,the client evaluated his pain at 3 out of 10."
3) "Turning the client every 2 hours has helped in the healing of the pressure ulcer on his coccyx."
4) "Since the client has been ambulating to the bedroom without difficulty,I'll walk with him to the dayroom after dinner."

Question 9

The client is scheduled to receive Coumadin (an anticoagulant)at 9:00 AM.His morning laboratory results show him to have a high partial thromboplastin time (PTT).His nurse decides to withhold the Coumadin.Which step of the implementation process is she using?
1) Reassessing the client
2) Stating an expected outcome
3) Revising the nursing diagnosis
4) Modifying the nursing care plan

Question 10

The plan of care offers a number of different types of nursing interventions that may be incorporated in.An example of a nurse implemented specific life-saving measure is:
1) Administering analgesics
2) Restraining a violent client
3) Initiating stress-reduction therapy
4) Teaching the client how to take his/her pulse rate

Question 11

The nurse recognizes the discharge needs of a client following a hip replacement.This is an example of which type of nursing skill?
1) Cognitive
2) Interactive
3) Psychomotor
4) Communication

Question 12

The primary reason for the establishment of standing orders is to:
1) Provide appropriate nursing autonomy in settings where client needs can change rapidly
2) Facilitate adequate care when direct contact with a primary health care provider is not immediately possible
3) Allow nurses to provide certain routine therapies without first notifying the primary health care provider
4) Afford the client interventions that reflect the appropriate standard of care in the absence of a primary health care provider

Question 13

Which of the following statements made by a new graduate nurse regarding the modification of a client's care plan requires immediate follow-up by the nurse's preceptor?
1) "I will review the care plan before I do my charting."
2) "The client prefers to bathe at night,so that's what I'll do."
3) "I gave her a bed bath this morning,but she could really manage showering herself."
4) "The order reads clear liquids,but I hear good bowel sounds and she's really hungry."

Question 14

To provide optimum care,a nursing intervention should be based on:
1) An appropriate nursing diagnosis
2) Subjective and objective client data
3) Sound clinical judgment and knowledge
4) Identified physical and psychosocial needs of the client

Question 15

For a client with a nursing diagnosis of impaired physical mobility related to bilateral arm casts,the nurse should select which of the following methods of nursing intervention?
1) Teaching
2) Counseling
3) Compensating for adverse reactions
4) Assisting with activities of daily living (ADLs)

Question 16

Which of the following statements made by a nurse practitioner best reflects an understanding of the availability of clinical practice guidelines?
1) "Clinical guidelines are so very helpful in providing the most up-to-date nursing care."
2) "I'm sure we could get a team together and develop a pressure ulcer prevention protocol or search sites for established protocols."
3) "I am particularly impressed by the type 2 diabetic guidelines posted on the National Guidelines Clearinghouse (NGC)site."
4) "I'm told that for gerontological issues,the Gerontological Nursing Interventions Research Center (GNIRC)is the primary resource site."

Question 17

Which of the following statements made by a new nursing graduate requires immediate follow-up by the nurse's mentor?
1) "Older clients with arthritis require additional time to complete to complete their own AM care."
2) "My client's wife says he loves chocolate milk so I will order his dietary supplement in chocolate."
3) "My client just received some bad news regarding her tests.I'll see if the chaplain can visit this evening."
4) "Teenage diabetics seem to have a more difficult time making good food choices in order to control their blood sugars."

Question 18

The nurse notes that a narcotic is to be administered "per epidural cath." The nurse;however,does not know how to perform this procedure.Which aspect of the implementation process should be followed?
1) Seek assistance
2) Reassess the client
3) Use interpersonal skills
4) Critical decision making

Question 19

Which of the following interventions best reflects the nurse's understanding of direct care interventions regarding a cognitively impaired client's need for social interaction?
1) Arranging for the client to attend a "sing along" in the dayroom
2) Helping the client place a long distance telephone call to his daughter
3) Turning the client's television on when his or her favorite program is playing
4) Talking about the client's favorite sport's team while redressing his or her wound

Question 20

Which of the following nursing actions is most likely a result of the nurse's clinical experience?
1) Placing an immobile client on a turning schedule
2) Always assessing a client's IV site before hanging a new bag of fluid
3) Requesting that the nursing assistant have vital signs recorded by 0815
4) Administering a pain medication 30 minutes before changing a burn dressing

Question 21

Which of the following statements regarding utilization of personnel made by a new graduate nurse requires immediate follow-up by the nurse's mentor?
1) "My LPN is really good with dressings,so I usually delegate them to her."
2) "I always take the time to ambulate a post op client the first time out of bed."
3) "I always try to help my nursing assistant with the clients who require a total bed bath."
4) "I have my nursing assistant take and document all vital signs and intake and outputs."