Chapter 19: Implementing Nursing Care

The nurse is asked to perform a complex intervention for a patient. However, the nurse is unable to perform it successfully. What would be the appropriate action by the nurse? 1. Continue until the intervention is successfully completed. 2. Ask for assistance from a senior nurse. 3. Tell the patient about the inability to perform it. 4. Modify the intervention to make it easy to perform.

Ask for assistance from a senior nurse.

IADLs Examples

Cleaning their house, helping them get groceries

Nursing interventions classification (NIC) interventions

Differentiates nursing practice from that of other health care disciplines

Isolation Precautions as a treatment intervention are an example of which type of care? A. Direct B. Indirect C. Prevention D. Safety

Indirect

The nurse is managing indirect care activities in a hospital. Which option is an example of this type of activity? 1. Infection control 2. Patient counseling 3. Medication administration 4. Diagnostic tests

Infection control

Indirect Care

Treatments performed away from the patient but on behalf of the patient or group of patients

indirect care

Treatments performed away from the patient but on behalf of the patient or group of patients

Direct Care

Treatments performed through interactions with patients

Indirect Care Examples

•Managing the patient's environment •Documentation •Interdisciplinary collaboration

Direct Care Examples

•Medication administration •Insertion of an IV infusion •Counseling during a time of grief

The nurse is planning a discharge for a patient. The nurse understands that the plan is designed based on the patient's activities of daily living (ADL). What factors should the nurse consider when making the plan? Select all that apply. 1. A paralyzed patient will need permanent assistance for ADLs. 2. The patient should be encouraged to participate in ADLs. 3. A patient with a fractured humerus will need permanent assistance for ADLs. 4. The family members should be allowed to assist the patient. 5. Only a professional nurse should provide the ADLs.

-A paralyzed patient will need permanent assistance for ADLs. -The patient should be encouraged to participate in ADLs. -The family members should be allowed to assist the patient.

A patient is diagnosed with a chronic illness. How should the nurse counsel the patient and the family members to encourage coping? Select all that apply. 1. Counsel them so that they can accept the change in health status. 2. Provide the patient emotional and psychological support. 3. Understand that a patient and family who need nursing counseling are psychologically disabled. 4. Assist the patient in managing stress and developing interpersonal relationships. 5. Understand that a patient requiring nursing counseling has normal adjustment difficulties and may be upset or frustrated.

-Counsel them so that they can accept the change in health status. -Provide the patient emotional and psychological support. -Assist the patient in managing stress and developing interpersonal relationships. -Understand that a patient requiring nursing counseling has normal adjustment difficulties and may be upset or frustrated.

The nurse performs cardiopulmonary resuscitation for a patient in cardiac arrest. What kind of action is this? Select all that apply. 1. Direct care 2. Counseling 3. Indirect care 4. Lifesaving measure 5. Battery

-Direct care -Lifesaving measure

The American Nurses Association (ANA) is a national nursing organization that directs quality nursing practice. What are the salient features of the ANA? Select all that apply. 1. It defines standards of professional nursing practice. 2 It sets standards for the diagnostic step of the nursing process. 3 It sets standards for the assessment step of the nursing process. 4 It sets standards for the implementation step of the nursing process. 5 It issues authoritative statements regarding the duties all nurses are expected to perform.

-It defines standards of professional nursing practice. -It sets standards for the implementation step of the nursing process. -It issues authoritative statements regarding the duties all nurses are expected to perform.

The nurse is responsible for managing all the supplies and equipment required for a patient's minor procedure. Which actions performed by this nurse are correct? Select all that apply. 1. Only keep the exact number of supplies as needed. 2. Keep some extra supplies handy. 3. Ensure that the equipment is safe and in working condition. 4. Unseal all the equipment and place close to the patient. 5. Place the equipment properly to ensure easy access during the procedure.

-Keep some extra supplies handy. -Ensure that the equipment is safe and in working condition. -Place the equipment properly to ensure easy access during the procedure.

The nurse is preparing to administer an intravenous (IV) antibiotic to a patient who has been admitted to the hospital with pneumonia. What should the nurse do when arranging supplies and equipment for this nursing procedure? Select all that apply. 1. Place the supplies in a convenient location. 2. Check whether the equipment is working properly. 3. Decide what supplies will be needed for the procedure. 4. Open the extra supplies and keep them ready for use. 5. Assume that all required supplies will be available.

-Place the supplies in a convenient location. -Check whether the equipment is working properly. -Decide what supplies will be needed for the procedure.

A patient has developed a hypersensitivity reaction to penicillin and has developed hives. What interventions should the nurse perform? Select all that apply. 1. Reduce the penicillin dose. 2. Record the reaction. 3. Inform the healthcare provider. 4. Administer diphenhydramine, an antihistamine and antipruritic medication, as ordered. 5. Reassure the patient.

-Record the reaction. -Inform the healthcare provider. -Administer diphenhydramine, an antihistamine and antipruritic medication, as ordered. -Reassure the patient.

A patient is admitted to the hospital for abdominal pain. The patient is instructed not to eat or drink anything by mouth for the next 24 hours. The patient also complains of nausea and vomiting. The healthcare provider orders an antiemetic drug for the patient. Following the administration of the drug, the patient develops adverse reactions. What should the nurse do? Select all that apply. 1. Record the reaction. 2. Stop further administration of the drug. 3. Call the healthcare provider. 4. Start oral antiemetic medication. 5. Stop the medication and administer it again after the reaction subsides.

-Record the reaction. -Stop further administration of the drug. -Call the healthcare provider.

The nurse is starting on the evening shift and is assigned to care for a patient with a diagnosis of deteriorated skin integrity related to pressure and moisture on the skin. The patient is 72 years old and had a stroke. The patient weighs 250 pounds and is difficult to turn. As the nurse makes decisions about how to implement skin care for the patient, which actions does the nurse implement? Select all that apply. 1. Review the set of all possible nursing interventions for the patient's problem. 2. Review all possible consequences associated with each possible nursing action. 3. Consider own level of competency. 4. Determine the probability of all possible consequences. 5. Evaluate the condition of the patient's skin.

-Review the set of all possible nursing interventions for the patient's problem. -Review all possible consequences associated with each possible nursing action. -Determine the probability of all possible consequences.

The nurse finds a document with standing orders in a hospital. Which statements about standing orders are correct? Select all that apply. 1. Standing orders are the orders given by the unit manager of the hospital in case of emergencies. 2. Standing orders are preprinted documents that contain orders for specific clinical problems. 3. Standing orders give legal protection to the nurse when acting in the patient's best interest. 4. Standing orders are signed by the licensed healthcare practitioner in charge at the time of implementation. 5. Standing orders are signed by the patient or the patient's relative before the treatment is started.

-Standing orders are preprinted documents that contain orders for specific clinical problems. -Standing orders give legal protection to the nurse when acting in the patient's best interest. -Standing orders are signed by the licensed healthcare practitioner in charge at the time of implementation.

The nurse performs various physical care techniques when caring for a patient. Which statements are true for physical care technique? Select all that apply. 1. Staying organized while caring for the patient 2. Protecting oneself and the patient from injury 3. Ensuring that the patient has his or her medical reports 4. Using proper hygienic infection control practices 5. Preparing a discharge summary and rehabilitation plan

-Staying organized while caring for the patient -Protecting oneself and the patient from injury -Using proper hygienic infection control practices

The nurse is starting an intravenous (IV) line for a patient. What information should the nurse provide to the patient? Select all that apply. 1. The name of the medication that is given through the IV line 2. The name of the nurse who will come to discontinue the IV fluid 3. The duration of time that the IV bag will last 4. An explanation of any physical sensations that the medication will cause 5. An explanation of the expected sensation if the IV fluid extravasates

-The name of the medication that is given through the IV line -The duration of time that the IV bag will last -An explanation of any physical sensations that the medication will cause -An explanation of the expected sensation if the IV fluid extravasates

Which steps does the nurse follow when he or she is asked to perform an unfamiliar procedure? Select all that apply. 1. The nurse seeks necessary knowledge. 2. The nurse reassesses the patient's condition. 3. The nurse collects all necessary equipment. 4. The nurse delegates the procedure to a more experienced staff member. 5. The nurse considers all possible consequences of the procedure.

-The nurse seeks necessary knowledge. -The nurse reassesses the patient's condition. -The nurse collects all necessary equipment. -The nurse considers all possible consequences of the procedure.

A newly hired nurse is asked to perform a procedure that the nurse has not previously performed. What should the nurse do in such a situation? Select all that apply. 1. Try to learn and obtain knowledge about the procedure. 2. Ask the unit manager to assign the procedure to another nurse. 3. Ask an experienced nurse to supervise and guide the new nurse during the procedure. 4. Verbalize the steps of the procedure with an instructor before performing it. 5. Refuse to perform the procedure.

-Try to learn and obtain knowledge about the procedure. -Ask an experienced nurse to supervise and guide the new nurse during the procedure. -Verbalize the steps of the procedure with an instructor before performing it.

ADLs Examples

-bathing -brushing teeth

Managing the patient's environment

-handwashing -PPE -safety and infection control -preparing yourself to interact with patient -putting PPE on outside the room

Physical care technique examples

-turning patient -proper body mechanics -safe and efficient handling -proper PPE

A patient is admitted to the hospital for abdominal pain. The patient is instructed to not eat or drink anything by mouth for the next 24 hours. The patient also complains of nausea and vomiting. The patient is not showing much improvement even after administration of antiemetic drugs. The nurse decides to change the nursing care plan. Arrange the steps that the nurse follows during modification of the existing plan. 1.Select the method of evaluation to determine the patient outcomes. 2.Revise specific interventions that correspond to the new diagnoses. 3.Delete nursing diagnoses that are no longer relevant and add new diagnoses. 4.Revise data to reflect the current health status of the patient.

1) Revise data to reflect the current health status of the patient. 2) Revise specific interventions that correspond to the new diagnoses. 3) Delete nursing diagnoses that are no longer relevant and add new diagnoses. 4) Select the method of evaluation to determine the patient outcomes.

How To Review/Revise Current Care Plan

1. Revise data in the assessment column to reflect the patient's current status. 2. Revise the nursing diagnoses. 3. Revise specific interventions that correspond to the new nursing diagnoses and goals. 4. Choose the method of evaluation for determining whether you achieved patient outcomes.

Clinical practice guidelines and protocols

A systematic set of statements that helps nurses, physicians, and other health care providers make decisions about appropriate health care for specific clinical situations

What emphasize implementing a timely plan following patient safety goals?

ANA Standards of Practice

Which nursing intervention is most appropriate for inclusion in the care plan of the patient with Crohn's disease who has undergone a double-contrast barium enema test? 1. Instruct the patient to eat potato chips. 2. Add more fluids to the patient's diet plan. 3. Remove fiber-rich foods from the patient's diet plan. 4. Give iron supplements to the patient 1 hour after the test.

Add more fluids to the patient's diet plan.

A patient develops skin rashes and hives after administration of penicillin. What is this phenomenon? 1. Aggravation 2. Amelioration 3. Adverse reaction 4. Therapeutic effect

Adverse reaction

When does implementation begin as the fourth step of the nursing process? 1. During the assessment phase 2. Immediately in some critical situations 3. After the care plan has been developed 4. After there is mutual goal setting between nurse and patient

After the care plan has been developed

Lifesaving measures Example

CPR

The nurse has to give instructions to a patient for foot care. What method does the nurse follow when communicating with the patient? 1. Give the instructions once in a loud and clear voice. 2. Give instructions and then ask the patient to repeat them all. 3. Give instructions slowly and clearly, and repeat them. 4. Give the instructions to the family and ask them to slowly explain them to the patient.

Give instructions slowly and clearly, and repeat them.

The nurse is caring for a patient. The patient has had diabetes for 10 years and comes to the hospital for regular checkups. The nurse finds that the patient has developed a nonhealing wound on the foot. The nurse prepares a nursing care plan for the patient. What activity should the nurse include in her nursing plan for indirect care? 1. Manage the patient's environment. 2. Administer medication on time. 3. Insert intravenous infusion. 4. Counsel the patient and the family members.

Manage the patient's environment.

What offers standardization to enhance communication of nursing care across settings & to compare outcomes?

NIC

Standing orders

Preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identified clinical problem

The nurse administers a polio vaccine to an infant. What is this level of prevention called? 1. Rehabilitation 2. Tertiary prevention 3. Primary prevention 4. Secondary prevention

Primary prevention

What helps nurses to anticipate and sequence nursing interventions?

Priorities

The nurse enters a patient's room, and the patient asks if he can get out of bed and transfer to a chair. The nurse takes precautions to use safe patient handling techniques and transfers the patient. Which type of physical care technique is this an example of? 1. Meeting the patient's expressed wishes 2. Indirect care measure 3. Protecting a patient from injury 4. Staying organized when implementing a procedure

Protecting a patient from injury

The nurse is reassessing a patient. The patient asks for a bedpan. The nursing assistive person (NAP) is in another room. What is the most appropriate nursing action? 1. Call the NAP and ask him or her to bring a bedpan for this patient and then return to the other patient. 2. Provide the bedpan to the patient and do not wait for the NAP who is with other patients. 3. Call the NAP and ask him or her to bring the bedpan after completing care of the other patient. 4. Reassure the patient that a bedpan is coming soon, and move on to the next patient to provide care.

Provide the bedpan to the patient and do not wait for the NAP who is with other patients.

The nurse applies critical thinking while implementing interventions with patients. Which action is the nurse likely to perform? 1. Carry out the interventions as per standing orders. 2. Review all potential complications associated with the interventions. 3. Carry out the interventions and be prepared for any complications. 4. Carry out the interventions as per the orders given by the healthcare practitioner.

Review all potential complications associated with the interventions.

What allows validation of a patient's nursing diagnoses, review the care plan, and determine whether the nursing interventions remain the most appropriate for the patient's needs?

Reviewing and revising the existing nursing care plan

The nurse finds a written order in the intensive care unit (ICU) that states in case of cardiac arrest, epinephrine is to be given to the patient. What type of order is this? 1. Protocol 2. Intervention 3. Prescription 4. Standing order

Standing order

2. You are writing a care plan for a newly admitted patient. Which one of these outcome statements is written correctly? A. The patient will eat 80% of all meals. B. The nursing assistant will set the patient up for a bath every day. C. The patient will have improved airway clearance by June 5. D. The patient will identify the need to increase dietary intake of fiber by June 5.

The patient will identify the need to increase dietary intake of fiber by June 5.

ANA Standards of practice

Used as evidence of the standard of care that RNs provide their patients

True or False: A clinical practice guideline is a collection of institutional policies that assist nurses, physicians, and other health care providers in making decisions about appropriate health care for specific clinical situations, such as the management of tuberculosis.

true

adverse reaction

undesirable drug effect

standing order

written in advance of a situation that is to be carried out under specific circumstances

counseling

a direct care method that helps a patient use a problem-solving process to recognize and manage stress and facilitate interpersonal relationships

Interpersonal skills

a nurse teaching a patient

lifesaving measure

a physical care technique that you use when a patient's physiological or psychological state is threatened

nursing intervention

an action or measure taken by the nursing team to help the person reach a goal

Activities of daily living (ADLs)

assistance may be temporary, permanent, or rehabilitative

Quality and Safety Education for Nurses (QSEN) skill competencies

authoritative statements of the duties that all RNs are expected to perform competently, regardless of role, patient population they serve, or specialty

Nurse & health care provider initiated standardized interventions

available in the form of clinical guidelines or protocols, standing orders, and NIC interventions

activities of daily living (ADLs)

basic self-care tasks such as eating, bathing, toileting, walking, and dressing

Reassessment is what kind of process?

continuous process with each patient interaction

American Nurses Association (ANA) standards

defines standards of professional nursing practice

1. Nurse-initiated interventions are: A. determined by state Nurse Practice Acts. B. supervised by the entire health care team. C. made in concert with the plan of care initiated by the physician. D. developed after interventions for the recent medical diagnoses are evaluated.

determined by state Nurse Practice Act

Quality and safety education for nurses (QSEN)

establishes standard competencies in knowledge, skills, & attitudes for the preparations of future nurses

implementation

fourth step of nursing process where nursing measures carried out during resident care

Reassessing a patient

gathering additional information to ensure plan of care is still appropriate for patient's level of wellness

Instrumental ADLs (IADLs)

includes shopping, preparing meals, house cleaning, writing checks, and taking medications

Psychomotor skills

incorporating knowledge with action

Is delegating, supervising, and evaluating the work of other staff members indirect or direct care?

indirect care

direct care

interventions are treatments performed through interactions with patients

Cognitive skills

knowledge

Indirect care measures

nursing actions that manage the patient care environment & interdisciplinary collaborative actions that support the effectiveness of direct care interventions

Patient adherence

patients and families invest time in carrying out required treatments

Lifesaving measures

physical care technique that you use when a patient's physiological or psychological state is threatened

interdisciplinary care plans

plans representing the contributions of all disciplines caring for a patient

Preventive nursing actions

promote health and prevent illness to avoid the need for acute or rehabilitative health care

clinical practice guidelines

recommendations based on evidence that serve as useful tools to direct clinical practice

What gives nurses legal protection to intervene appropriately in the best interests of patients with rapidly changing needs?

standing orders

instrumental activities of daily living (IADLs)

the activities of daily living needed for independent living like shopping, preparing meals, housekeeping and taking meds

Physical care techniques

the safe and competent administration of nursing procedures

QSEN Goal

to prepare nurses so they can continuously improve the quality and safety of the health care systems within which they work