(Fund Ch 17) PrepU Questions

After learning about a client's limited financial resources and limited insurance benefits, the home care nurse modifies nursing interventions related to a client's care instructions. The nurse modifies the plan of care based upon which client variable? a. Psychosocial background b. Developmental stage c. Research findings d. Current standards of care

a. Psychosocial background The nurse is demonstrating an awareness of the client's psychosocial background, which includes consideration of the client's socioeconomic status. Research findings and current standards of care are examples of nursing variables. Developmental stage is a client variable that addresses the developmental needs of a client.

The client tells the nurse, "I think the nurse last night may have given me the wrong medication, but I was afraid to say anything." What is the nurse's most appropriate response? a. "I will report your concerns to the nurse manager." b. "I will discuss your concerns with the night nurse." c. "You should always speak up if you have any questions about your care." d. "You always have the right to refuse any medication or treatment."

c. "You should always speak up if you have any questions about your care." The priority is to empower the client into taking an active role in the client's care, so the nurse should tell the client to feel free to ask questions. The client does have the right to refuse, but this does not address the issue. Speaking to the nurse manager or the night nurse does not help the client deal with a similar situation in the future.

Which statement best explains why continuing data collection is important? a. It is difficult to collect complete data in the initial assessment. b. It is the most efficient use of the nurse's time. c. It enables the nurse to revise the care plan appropriately. d. It meets current standards of care.

c. It enables the nurse to revise the care plan appropriately. Continuous data collection ensures that the nurse has the most current client data to evaluate, which allows for updating the care plan as needed. A complete assessment is performed on admission, but the client's condition is always changing. The purpose of continued data collection is to provide good client care; it does not relate directly to efficiency of nursing care. While continuous data collection meets standards of care, it is not the primary reason for ongoing assessments.

The nurse has assisted the client to ambulate for the first time. After returning the client to bed, what is the nurse's priority intervention? a. Assess the client's response to the ambulation. b. Inform the client when ambulation is scheduled next. c. Discuss the client's feelings about the illness. d. Document the client's ambulation.

a. Assess the client's response to the ambulation. After a nurse has performed an intervention, the next step is to evaluate the effectiveness of the intervention. The nurse should assess the client's response to the ambulation. Informing the client when ambulation is scheduled next, discussing the client's feelings, and documenting the ambulation are important, but not until after the client has been reassessed.

Priority setting is based on the information obtained during reassessment and is used to rank nursing diagnoses. Each factor contributes to priority setting except which? a. Finances of the client b. The client's condition c. Time and resources d. Feedback from the family

a. Finances of the client The client's condition, time and resources, and feedback or input from the family are all of great value when the nurse is prioritizing the client's nursing diagnoses. The client's finances, however, should not influence the nurse's priority setting. The nursing code of ethics states that clients should receive the same treatment regardless of their ability to pay.

The nurse is coordinating care for a client with continuous pulse oximetry who requires pharyngeal suctioning. To which staff member should the nurse avoid delegating the task of suctioning? a. Registered nurse b. Nursing assistant who is a nursing student c. A senior nursing student present for clinical d. Licensed practical nurse

b. Nursing assistant who is a nursing student The nurse should avoid delegating this client to the nursing assistant who is a nursing student. Suctioning and the associated evaluation of the client would be within the scope of practice of the registered nurse, licensed practical nurse, and the senior nursing student present for clinical.

The client is having difficulty breathing. The respiratory rate is 44 and the oxygen saturation is 89% (0.89 L). The nurse raises the head of the bed and applies oxygen at 3 L/min per nasal cannula. How does the nurse determine the effectiveness of the interventions? Select all that apply. a. The client's respiratory rate decreases. b. The client states, "I can breathe easier now." c. The client's oxygen saturation level increases. d. The client is watching television. e. The client's family asks if the client is going to be okay.

a. The client's respiratory rate decreases. b. The client states, "I can breathe easier now." c. The client's oxygen saturation level increases. When reassessing the client after implementing interventions to increase oxygenation, the nurse would look for a decrease in respiratory rate to a more normal rate and an increase in the oxygen saturation level. The client's subjective statement of breathing easier would also indicate effectiveness. The client watching television and the client's family's statement do not indicate anything about oxygenation status.

The registered nurse (RN) is delegating the task of assisting a postoperative client to the bathroom to the unlicensed assistive personnel (UAP). The nurse witnessed the UAP correctly perform the task on previous occasions and knows the UAP is competent to perform the task. The nurse has communicated how to get the client out and back into bed and told the UAP not to allow the client to bear weight on the left leg. The nurse validated that the activity was completed and gave the UAP feedback. Which delegation guideline did the nurse omit? a. Right task b. Right circumstance c. Right person d. Right supervision

b. Right circumstance The nurse fails to follow the delegation guideline related to right circumstance. The RN did not assess the client's needs or identify the outcome to be achieved by the task that was delegated. The other guidelines were followed.

When the nurse is administering medication, an older adult client states, "Why does everyone keep asking my name? I've been here for days." How should the nurse respond to the client? a. "It is a habit that nurses develop in school." b. "It is a hospital policy to reduce the potential for errors." c. "We ask your name to ensure that we are treating the right client." d. "We ask your name to show that we respect your rights."

c. "We ask your name to ensure that we are treating the right client." The primary reason for asking the client to state the client's name is to ensure that the nurse is dealing with the correct client. Asking the client to state the client's name is a habit that should be developed in nursing school, but that is not the reason nurses ask clients for their names. It is not just a hospital-specific policy to ask the client for the client's name, but it is a step that is used in all client care situations. Respecting clients' rights is important but that is not why nurses ask for their names.

A nurse is administering metformin to a client who has a new onset of diabetes mellitus type 2. Which step should the nurse consider a priority on the nursing care plan? a. Restrict intake of foods and fluids. b. Monitor for noncompliance. c. Monitor for lactic acidosis d. Administer B12 injections

c. Monitor for lactic acidosis In this scenario, the nurse is administering a medication. Because an action is being carried out, this is the implementation step of the nursing process. Following the administration of medication, the nurse should monitor the client for lactic acidosis as well as side effects of the medication. Restricting the client's food and fluids while the client is on metformin is only suggested when the client is preparing for a procedure requiring the client to be NPO. B12 injections may be indicated in the future as treatment has been established. Likewise, it is too early in the treatment plan to monitor for noncompliance.

A client is diagnosed with hypertension, placed on a low-sodium diet, and given smoking cessation literature. The nurse observes the client eating from a fast food restaraunt bag that a family member brought in and the client states, "I don't think I can do this." What is the nurse's first objective when implementing care for this client? a. Explain the effects of a high-salt diet and smoking on blood pressure. b. Identify what barriers the client feels are preventing adherence with the plan. c. Collaborate with other health care professionals about the client's treatment. d. Change the nursing care plan.

Identify what barriers the client feels are preventing adherence with the plan. The nurse must first identify why the client is not following the therapy before collaboration with other health care professionals or a change in the nursing care plan can be initiated. Simply explaining the effects of a high-salt diet and smoking on the blood pressure may not address the underlying cause of why the client is choosing not to follow the recommended care.

The nurse is attending a conference on evidence-based practice. Which statement by the nurse indicates further education is needed? a. "I must conduct research to validate the usefulness of my nursing interventions." b. "I can learn about evidence-based practice by reading professional nursing journals." c. "Nursing interventions should be supported by a sound scientific rationale." d. "The Agency for Healthcare Research and Quality is a resource for evidence-based practice."

a. "I must conduct research to validate the usefulness of my nursing interventions." Nursing interventions should be supported by a sound scientific rationale; however, nurses do not need to personally conduct research to establish the rationale for nursing interventions. Nurses can learn about evidence-based practice by reading professional nursing journals, attending nursing workshops, and consulting evidence-based practice resources, such as the Agency for Healthcare Research and Quality.

A nurse is providing care to several assigned clients and decides to delegate the task of morning vital signs to unlicensed assistive personnel. The nurse would assume responsibility and refrain from delegating this task for which client? a. A client with a high fever receiving intravenous fluids, antibiotics, and oxygen b. An older adult with pneumonia who is being discharged to the son's home tomorrow c. A middle-aged client who had abdominal surgery 3 days ago and is ambulating in the hall d. An adult client who is being treated for kidney stones

a. A client with a high fever receiving intravenous fluids, antibiotics, and oxygen For delegation, the circumstances must be right. The health condition of the client must be stable. The client with a high fever receiving intravenous fluids, antibiotics, and oxygen is the least stable of the clients listed and should be assessed by the nurse. Delegation of taking vital signs would be appropriate for all of the other client's described.

Which type of nursing intervention is oxygen administration and why is it considered to be so? a. A dependent nursing intervention, because oxygen is considered a drug that requires a physician's order b. A collaborative nursing intervention, because it is ordered by the respiratory therapist c. An independent nursing intervention, because nurses have the necessary skill to administer oxygen d. An interdependent intervention, because physicians, nurses, and respiratory therapists have the necessary skill to administer oxygen

a. A dependent nursing intervention, because oxygen is considered a drug that requires a physician's order Oxygen administration is a dependent nursing intervention because it requires a physician's order. Independent nursing interventions are autonomous actions based on scientific rationale that a nurse executes to benefit the client in a predictable way related to the nursing diagnosis and expected outcomes. Nursing-initiated interventions, such as teaching, providing fluids, and assisting with guided imagery, do not require a physician's order. Collaborative and interdependent are not types of nursing interventions.

Which examples of nursing actions involve direct care of the client? Select all that apply. a. A nurse counsels a young family who is interested in natural family planning. b. A nurse massages the back of a client while performing a skin assessment. c. A nurse arranges for a consultation for a client who has no health insurance. d. A nurse helps a client in hospice fill out a living will form. e. A nurse arranges for physical therapy for a client who had a stroke.

a. A nurse counsels a young family who is interested in natural family planning. b. A nurse massages the back of a client while performing a skin assessment. d. A nurse helps a client in hospice fill out a living will form. A direct care intervention is a treatment performed through interaction with the client(s). Direct care interventions include both physiologic and psychosocial nursing actions, and include both the "laying of hands" actions and those that are more supportive and counseling in nature. An indirect care intervention is a treatment performed away from the client but on behalf of a client or group of clients. Indirect care interventions include nursing actions aimed at management of the client care environment and interdisciplinary collaboration.

Which nursing intervention is most likely to be allowed within the parameters of a protocol or standing order? a. Administering a glycerin suppository to a constipated client who has not responded to oral stool softeners b. Changing a client's intravenous (IV) fluid from normal saline to 5% dextrose c. Administering a beta-adrenergic blocker to a new client whose blood pressure is high on admission assessment d. Changing a client's advance directive after the prognosis has significantly worsened

a. Administering a glycerin suppository to a constipated client who has not responded to oral stool softeners Standing orders and protocols often surround the management of bowel elimination. Modification of a client's IV fluid or administration of a new antihypertensive are client-specific interventions that are physician initiated. The care team cannot independently change a client's advance directive.

One hour after receiving pain medication, a postoperative client reports intense pain. What is the nurse's appropriate first action? a. Assess the client to determine the cause of the pain. b. Consult with the physician for additional pain medication. c. Discuss the frequency of pain medication administration with the client. d. Assist the client to reposition and splint the incision.

a. Assess the client to determine the cause of the pain. One hour after administering pain medication, the nurse would expect the client to be relieved of pain. A new report of intense pain might signal a complication and requires a thorough assessment. The nurse might request an order for additional pain medication, but only after a thorough assessment. Telling the client how often medication can be received does not help relieve the client's pain. Repositioning and splinting the incision are interventions that the nurse might perform, but only after determining the cause of the pain.

The nurse is preparing to administer a blood pressure medication to a client. To ensure the client's safety, what is the priority action for the nurse to take? a. Assess the client's blood pressure to determine if the medication is indicated. b. Determine the client's reaction to the medication in the past. c. Ask the client to verbalize the purpose of the medication. d. Tell the client to report any side effects experienced.

a. Assess the client's blood pressure to determine if the medication is indicated. Before initiating any intervention, the nurse must determine if the intervention is still necessary. Before administering blood pressure medication, the blood pressure must be assessed. The client's reaction to the medication previously does not indicate if the medication is indicated at this time. The client's ability to verbalize the purpose of the medication is important to promote self-care, but it is not important for the client's safety at this time. The client's report of side effects would indicate an adverse reaction after the medication is administered, but it would not protect the client's safety before the medication is given.

Which nursing action can be categorized as a surveillance or monitoring intervention? a. Auscultating of bilateral lung sounds b. Providing hygiene c. Administering a paracetamol tablet d. Use of therapeutic communication skills

a. Auscultating of bilateral lung sounds Surveillance or monitoring nursing interventions include detecting changes from baseline data and recognizing abnormal responses. Nurses rely on the senses to detect changes: observing the appearance and characteristics of clients; hearing by auscultation, pitch, and tone; detecting odors and comparing them with past experience and knowledge of specific problems; and using touch to assess body temperature, skin condition, clamminess, or diaphoresis. Nurses use all of these surveillance or monitoring activities to determine the current status of clients and changes from previous states. Nurses often detect subtle changes in a client's condition and communicate them to the physician to minimize problems. Providing hygiene and administering a paracetamol tablet are examples of maintenance nursing interventions. Use of therapeutic communication skills is an example of a supportive nursing intervention.

Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? a. Bed bath for the newly admitted client who has multiple skin lesions b. Preparation of insulin for the diabetic client with an elevated blood glucose level c. Ambulation of the client with a history of falls for the first time after surgery d. Insertion of a urinary catheter in a client with benign prostatic hypertrophy

a. Bed bath for the newly admitted client who has multiple skin lesions The safest delegation is to have the UAP bathe the client with skin lesions and report any abnormal findings to the nurse. Preparing insulin is outside of the UAP's scope of practice. The UAP may have the skills to insert an indwelling catheter and ambulate clients, but the clients involved each have qualifiers that complicate the tasks.

half of what the doctor ordered." How would the nurse most effectively meet this client's need? a. Collaborate with other disciplines to determine the best way to meet the client's medication requirements. b. Reinforce to the client and family the necessity of taking all medication as ordered to stabilize the client's condition. c. Inform the physician of the need to prescribe a less expensive medication for the client's condition. d. Instruct the client that some pharmaceutical companies have programs to help with medication expenses.

a. Collaborate with other disciplines to determine the best way to meet the client's medication requirements. In order to meet the client's needs, it is most important to involve other disciplines in the client's care to utilize all available resources. Reinforcing the importance of the medication does not solve the financial problem. It may be necessary for the physician to prescribe a less expensive medication, but other options should be considered to address the holistic needs of the client. Some pharmaceutical companies have programs to help with medication expenses, but the client will need information in order to apply for the programs.

A client in the last stages of pancreatic cancer tells the nurse, "I am tired of fighting. I am ready to die." What is the nurse's best action? a. Collaborate with other disciplines to plan end-of-life care for the client. b. Research other treatment options available for the client. c. Remind the client that positive thoughts are essential for recovery. d. Ask if the client would like to speak with a spiritual adviser.

a. Collaborate with other disciplines to plan end-of-life care for the client. The client has indicated an acceptance of the terminal condition. To respect the client's wishes, the nurse should involve other disciplines, such as hospice care, in planning for the client's needs. The client has not asked the nurse for other treatment options, so researching other options is not honoring the client's wishes. Reminding the client to think "positive thoughts" dismisses the seriousness of the client's concerns. Speaking with a spiritual adviser might be part of the collaborative care, but it would not address all the client's needs.

Discharge plans for a client with a mental health disorder include living with family members. The nurse learns that the family is no longer willing to allow the client to live with them. What is the nurse's most appropriate action? a. Collaborate with other disciplines to revise the discharge plans. b. Instruct the client to make alternate living arrangements. c. Communicate with the physician about additional orders. d. Inform the family that it is not possible to change the discharge plans.

a. Collaborate with other disciplines to revise the discharge plans. The discharge needs of this client are complicated, and the nurse will need the assistance of other disciplines to make a successful discharge plan. The client should have input into the future living arrangements, but the client does not have the resources to make the arrangements alone. The physician may be involved in the discharge plan, but additional orders are not necessary. It is not true (and would be inappropriate) to tell the family that discharge plans cannot be changed. If the family is unwilling to take the client, the placement will be unsuccessful.

The nurse is caring for a vegetarian who has iron deficiency anemia. The standardized nutritional plan for a client with anemia calls for the client to increase consumption of animal protein. How should the nurse plan to meet this client's nutritional needs? a. Collaborate with the nutritionist to modify the nutritional plan. b. Instruct the client that consumption of animal protein is necessary to cure the anemia. c. Meet with the client's family to emphasize the importance of nutritional modification. d. Arrange for animal protein to be disguised in the client's meal.

a. Collaborate with the nutritionist to modify the nutritional plan. A vegetarian does not consume animal proteins. Although animal proteins are an important source of iron, plant proteins are available. To honor the preferences of the client, the nurse would collaborate with the nutritionist to include these plant sources of protein in the client's diet (instead of the animal protein). It is not true that the client has to consume animal protein to cure the anemia. Meeting with the client's family would be inappropriate because this would violate the wishes of the client. Arranging for animal protein to be disguised in the client's meal would violate the client's trust and would also not be effective in the long term after the client has been discharged.

The nurse must give instructions before discharge to a 13-year-old in a sickle cell crisis. Three of the client's friends from school are visiting. In order to assure effective instruction, what should the nurse plan to do? a. Delay the instruction until the visitors leave. b. Give the visitors instructions to leave in 10 minutes. c. Ask the client if the client has any questions. d. Leave written information for the client to read later.

a. Delay the instruction until the visitors leave. The nurse must take into consideration the client's developmental level and willingness to participate in care in order to successfully implement the plan of care. The client is a teenager and socialization with a peer group is essential, so the nurse would most appropriately wait until the visitors leave. Telling the visitors to leave in 10 minutes might upset the client and hinder the education. Simply asking if the client has questions does not appropriately educate the client. Leaving written information does not ensure that the client will read or understand the information.

The client is in a rehabilitation unit after a traumatic brain injury. In order to facilitate the client's recovery, what would be the nurse's most appropriate intervention? a. Encourage the client to provide as much self-care as possible. b. Perform all care activities for the client to facilitate rest. c. Teach the family to anticipate the client's needs to care for the client. d. Arrange with the nurse case manager for an early discharge.

a. Encourage the client to provide as much self-care as possible. The nurse must encourage the client to provide as much self-care as possible in order to achieve the highest level of independence. Performing all care activities for the client makes the client dependent on the nurse. If the family anticipates and meets all the client's needs, this also hinders the client's recovery. An early discharge is not indicated because the client must be sufficiently recovered.

During morning report, the night nurse tells the oncoming nurse that the client has been medicated for pain and is resting comfortably. Thirty minutes later, the client calls and requests pain medication. What is the nurse's appropriate first action? a. Go to the client and assess the client's pain. b. Determine the frequency of pain medication. c. Medicate the client with the ordered pain medication. d. Instruct the client in nonpharmacologic pain management.

a. Go to the client and assess the client's pain. The nurse's first action should always be to determine the cause of the client's pain in order to determine the correct intervention. After determining the cause, the nurse can plan how to proceed. The other steps would be appropriate, but only after the assessment.

A client recovering after an appendectomy is reporting pain. The nurse administers the ordered pain medication and assists the client to splint the incision. What is the nurse's next step in implementing the plan of care? a. Reassess the client to determine the effectiveness of the interventions. b. Instruct the client that pain medication is available at regular intervals. c. Notify the physician that the client has required pain medications. d. Perform additional nonpharmacological pain interventions.

a. Reassess the client to determine the effectiveness of the interventions. After implementing any interventions (such as pain medication or any nonpharmacological pain control method, such as splinting the incision), the nurse must always reassess the client to determine the effectiveness of the interventions. It is more likely that the pain medication is available on an as-needed basis rather than at regular intervals; in any case, informing the client of the availability of pain medication is of lower priority than reassessing the client to determine the effectiveness of the interventions performed. There is no need to inform the physician that the client has required pain medication; the physician anticipated the client needing pain medication, which is why the physician ordered the medication for the client to begin with. After evaluating the effectiveness of the implemented interventions, if the nurse finds that they have been ineffective, then the nurse would then revise the plan and include additional interventions, including, possibly, other nonpharmacological pain interventions.

A nurse in the intensive care unit (ICU) has been assigned to care for a client who was seriously injured during a gang rape. The nurse was raped 6 months ago and fears being too upset to care for the client properly. How should the nurse deal with the assignment? a. Recognize the nurse's own limitations and ask for another nurse to be assigned. b. Recognize that the nurse may be faced with this issue again and care for the client. c. Recognize the nurse's own limitations and ask another nurse to assist if the nurse becomes too emotional. d. Recognize the issue and care for the client to the best of the nurse's ability.

a. Recognize the nurse's own limitations and ask for another nurse to be assigned. The nurse should keep the client's best interests in mind. If the nurse feels that the nurse's emotional state would compromise the client's care, the best course would be for the nurse to request a different assignment. The other courses of action leave the possibility that the client's care could be compromised.

A nurse in the intensive care unit (ICU) has been assigned to care for a client who was seriously injured during a gang rape. The nurse was raped 6 months ago and fears being too upset to care for the client properly. How should the nurse deal with the assignment? a. Recognize the nurse's own limitations and ask for another nurse to be assigned. b. Recognize that the nurse may be faced with this issue again and care for the client. c. Recognize the nurse's own limitations and ask another nurse to assist if the nurse becomes too emotional. d. Recognize the issue and care for the client to the best of the nurse's ability.

a. Recognize the nurse's own limitations and ask for another nurse to be assigned. The nurse should keep the client's best interests in mind. If the nurse feels that the nurse's emotional state would compromise the client's care, the best course would be for the nurse to request a different assignment. The other courses of action leave the possibility that the client's care could be compromised.

The nurse is preparing to give the client a bath early in the morning. The client states, "I prefer to take my bath at night. It helps me sleep." What is the nurse's most appropriate action? a. Reschedule the client's bath to the evening shift. b. Ask the client for permission to give the bath in the morning. c. Tell the client that the physician has ordered sleep medication if necessary. d. Determine whether the nurses have time to give the client's bath at night.

a. Reschedule the client's bath to the evening shift. The client's preferences are a primary consideration in scheduling interventions. The client's preference to have a bath at night requires a change in scheduling. Asking for permission to give the bath in the morning does not address the client's preference. The schedule of the nurses should not take priority over client needs. Informing the client about sleep medication does not address the client's preference.

Nursing interventions for the client after prostate surgery include assisting the client to ambulate to the bathroom. The nurse concludes that the client no longer requires assistance. What is the nurse's best action? a. Revise the care plan to allow the client to ambulate to the bathroom independently. b. Continue assisting the client to the bathroom to ensure the client's safety. c. Consult with the physical therapist to determine the client's ability. d. Instruct the client's family to assist the client to ambulate to the bathroom.

a. Revise the care plan to allow the client to ambulate to the bathroom independently. The intervention of assisting the client to the bathroom is no longer indicated, so the nurse would appropriately revise the care plan to discontinue that intervention. A consult with a physical therapist is not necessary to verify the nurse's independent assessment. If the client is safe to ambulate to the restroom independently, it is not necessary for the family to assist.

While observing a new nurse inserting an indwelling urinary catheter, the preceptor observes a break in sterile technique. What is the preceptor's first action? a. Tell the new nurse that a break in sterile technique has occurred and the procedure must be stopped. b. Allow the new nurse to continue with the insertion and discuss the error later away from the client. c. Report the new nurse's error to the nurse manager for corrective action. d. Assign the new nurse to view videos on sterile catheter insertion.

a. Tell the new nurse that a break in sterile technique has occurred and the procedure must be stopped. The most important priority is to ensure the client's safety. Because the new nurse has contaminated the sterile field, the risk of introducing infection is high. The procedure must be discontinued. Because the preceptor is working with the new nurse, it would not be necessary to report the new nurse's error to the nurse manager unless it became a pattern of behavior. Assigning the nurse to watch instructional videos might be appropriate, but after the client care issue is resolved.

The nurse is caring for a 10-year-old client who is newly diagnosed with a seizure disorder. What variable would alter the nurse's plan for educating the client and parent? a. The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years. b. The client expresses a desire to learn how to manage the medication regime. c. The parents verbalize acceptance of the need to closely monitor their child's condition. d. The parents have comprehensive insurance coverage for their family's medical care.

a. The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years. If the family has experience caring for a child with a seizure disorder, the family would already have some basic knowledge, so the nurse would address the education differently. The client expressing a desire to learn indicates receptiveness to the education. The parents' acceptance of their child's condition indicates that they are ready to begin dealing with the child's condition. The fact that the child has comprehensive insurance coverage is a strength that will make options available to the family, but will not necessarily change the nurse's educational plan.

A client who has been in a vegetative state for years is scheduled for an elective surgery. The nurse is questioning whether the procedure is necessary. What is the nurse's appropriate first action? a. The nurse should address the concern with the surgeon. b. The nurse should address the concern with the hospital attorney. c. The nurse should address the concern with the hospital ethics committee. d. The nurse should address the concern with the client's family.

a. The nurse should address the concern with the surgeon. The nurse should first address the concern with the surgeon who has scheduled the procedure. If the nurse still has concerns after the discussion with the surgeon, the other choices are possible courses of action.

A nurse who is experienced caring only for well babies is assigned to the neonatal intensive care unit (NICU) because of a shortage of nurses in the NICU. The nurse is assigned to an infant on a ventilator who will require blood transfusions during the shift. What is the nurse's most appropriate course of action? a. The nurse should inform the charge nurse that the nurse does not have the experience to properly care for this client. b. The nurse should ask another nurse who was previously assigned to the client for instruction. c. The nurse should request that the blood transfusions be delayed until the next shift. d. The nurse should recognize the necessity of the assignment and provide care to the best of the nurse's ability.

a. The nurse should inform the charge nurse that the nurse does not have the experience to properly care for this client. The nurse should recognize that the nurse lacks the competence to safely care for a client with these complex needs and inform the charge nurse of the fact. This assignment would be an inappropriate delegation on the part of the charge nurse and could cause injury to the client. The other options do not take the safety of the client into consideration.

A client with diabetes who has been closely following the prescribed plan of care for over a year is being seen at an outpatient facility. The client has not brought a log of daily glucose checks and tells the nurse, "I haven't been doing them regularly." What is the nurse's most therapeutic statement to the client? a. "It is extremely important to your health to strictly follow your plan of care." b. "It seems like you are having difficulty with your care regimen." c. "Should I arrange for a home health nurse to coordinate your care?" d. "Should I instruct your family to do the glucose checks for you?"

b. "It seems like you are having difficulty with your care regimen." The nurse's open-ended statement acknowledging that the client is having difficulty with the care regimen encourages the client to discuss what has occurred that has caused the client to not manage the diabetes as was previously done. The statement reminding the client that health care is important will discourage the client to freely discuss any problems. A home health nurse or instructions given to the family may be indicated, but not until the client has verbalized the reasons why the care regimen has not been followed.

A nurse suspects that the client with Crohn's disease does not understand the medication regimen or diet modifications required to manage the illness. What is the nurse's most appropriate action? a. Ask the gastroenterologist to explain the treatment plan to the client and family again. b. Ask the client to verbalize the medication regimen and diet modifications required. c. Ask the nutritionist to give the client strict meal plans to follow. d. Refer the client to available community resources and support groups.

b. Ask the client to verbalize the medication regimen and diet modifications required. If the nurse suspects a client does not understand instructions, the first step is to assess the client's understanding. The most effective way to do that is to have the client repeat the client's understanding of the instructions. The other steps might be interventions that the nurse would institute after determining the client's needs.

An unlicensed assistive personnel (UAP) has worked on the postpartum unit for many years. The UAP has been oriented well and provides excellent client care. What duties could the professional nurse appropriately delegate to the UAP? Select all that apply. a. Initial assessment of the mother after birth of the infant b. Assisting the client with personal hygiene needs and ambulation c. Assisting and teaching the client to breastfeed the infant d. Providing routine discharge instructions related to infant care e. Transporting the infant to the mother's room according to hospital policy

b. Assisting the client with personal hygiene needs and ambulation e. Transporting the infant to the mother's room according to hospital policy It is essential when delegating duties that the registered nurse (RN) is aware the nurse's role and what duties can be delegated. The nurse also must be aware of the training and the competence of the UAP. The nurse could appropriately delegate assisting with personal hygiene needs, ambulation, and transporting the infant to the mother's room according to hospital policy. Assessment is the role of the RN and cannot be delegated. Teaching, including breastfeeding education and discharge instructions, is also the role of the RN and cannot be delegated.

A client tells the nurse, "My doctor has told me I have to have a blood transfusion, but I am a Jehovah's Witness and I can't take one." What is the nurse's most appropriate intervention? a. Discuss the risks and benefits of a blood transfusion with the client. b. Discuss possible alternatives to a blood transfusion with the physician. c. Discuss the client's options with other church members. d. Discuss the client's refusal with hospital risk managers.

b. Discuss possible alternatives to a blood transfusion with the physician. As coordinator of the client's care, the nurse functions as an intermediary between the physician and the client. In order to honor the client's wishes, the nurse would most appropriately consult with the physician to meet the client's physical needs, as well as the client's spiritual needs. The risk and benefits of a blood transfusion are not the relevant issue with the client. Discussing the client's options with other church members would violate the client's privacy and would not meet the client's physical needs. It might be advisable to discuss the client's refusal of care with the hospital risk manager to protect the legal requirements of the institution, but it is not the priority.

A nurse is catheterizing a client. Which scenario demonstrates steps the nurse would take to ensure client respect and privacy? a. Verify the client's identifiable information, explain the procedure to the family, and pull the privacy curtain to allow the client to feel comfortable in having family close by. b. Explain the procedure to the client, close the door to the room, and cover all areas of the client, only exposing the area for catheterization. c. Ask family members to leave the room briefly, close the door, and ask the client if he or she would like a sheet to cover oneself. d. Bring in another nurse to provide support and prevent questionable behaviors, explain the procedure to the client, and close the door and privacy curtain prior to beginning the procedure.

b. Explain the procedure to the client, close the door to the room, and cover all areas of the client, only exposing the area for catheterization. It is important to think about the environment for each intervention. Pay special attention to respecting the client's privacy and dignity; for example, close the door to the room or pull the drapes between the beds. To demonstrate respect, the procedure should be explained to the client and all areas except the sterile area should be covered to protect modesty and privacy. Asking another nurse to assist is helpful, but not required and may make the client feel awkward. There is not need to discuss with the family, because the client does not have any cognitive issues.

The nurse is preparing a client with a bowel obstruction for emergency surgery. Which intervention has the highest priority for this client? a. Discuss discharge plans with the client. b. Inform the client what to expect after the surgery. c. Instruct the client and family in wound care. d. Teach the client about dietary restrictions during recovery.

b. Inform the client what to expect after the surgery. If the surgery is an emergency, the highest priority is to meet the client's immediate needs. The nurse should inform the client about what to expect after surgery. Discussing discharge plans, instructing in wound care, and teaching about dietary restrictions are important, but not necessary before the surgery.

Which nursing action would be most effective in helping a client learn self-care behaviors? a. Check with the client to ensure that personal self-care goals are being met. b. Model self-care behaviors for the client. c. Collect data on the number of self-care activities the client has performed that day. d. Ask client to discuss the client's goals for the day at the start of the shift.

b. Model self-care behaviors for the client. Modeling self-care behaviors is a nursing intervention and is the action most effective in helping the client learn the self-care behaviors. The other answer options refer to evaluation of the client's response to interventions related to learning self-care behaviors.

The nurse is assigned a client who had an uneventful colon resection 2 days ago and requires a dressing change. To which nursing team member should the nurse avoid delegating the dressing change? a. Registered nurse b. Nursing assistant c. A senior nursing student present for clinical d. Licensed practical nurse

b. Nursing assistant The nurse should avoid delegating the dressing change to the nursing assistant. The dressing change would be within the scope of practice of the registered nurse, licensed practical nurse, and the senior nursing student.

The emergency room (ER) has a strict protocol regarding intramuscular (IM) injection technique. A nurse working in the ER has learned of a new technique to decrease pain with IM injections from the nursing literature and would like to use it. What is the most appropriate way for the nurse to implement the technique? a. Begin using the technique to determine whether it is effective. b. Petition to change the protocol based on the new evidence. c. Ask the ER physician to order IM injections with the new technique. d. Research the protocols at other area emergency rooms.

b. Petition to change the protocol based on the new evidence. The nurse should petition to change the protocol on the basis of the new evidence. If the nurse believes that the change would be beneficial to clients, it is important to change the procedure for all clients. Therefore, having the ER physician write orders would not be the best choice because it would not affect all clients. Because the nurse must function under the protocols of the agency, it would be wrong to begin using the technique before the protocol is changed. Protocols at other area emergency rooms are not as authoritative as evidence from the nursing literature.

The nurse has instructed the client in self-catheterization, but the client is unable to perform a return demonstration. What is the nurse's most appropriate plan of action? a. Teach the content again utilizing the same method. b. Reassess the appropriateness of the method of instruction. c. Revise the plan to include the inclusion of a support group. d. Report the client's inability to learn to the case manager.

b. Reassess the appropriateness of the method of instruction. It is the nurse's responsibility to revise the plan of care if an intervention is not successful. The most appropriate action of the nurse would be to determine if the initial education was the most effective for this client. Simply teaching the content again without reassessing the client's needs would not necessarily be effective. A support group might be helpful, but not until the client's needs are evaluated. The case manager is not responsible for the client's learning.

An indwelling urinary catheter has been ordered for a client experiencing urinary retention after surgery. When the nurse enters the room to place the catheter, the client reports voiding in the bathroom. Which is the nurse's most appropriate action? a. Insert the urinary catheter as ordered to relieve the urinary retention. b. Reassess whether the client still needs the urinary catheter. c. Instruct the client that the catheter is essential to check for urinary retention. d. Inform the client that the catheter will no longer be necessary.

b. Reassess whether the client still needs the urinary catheter. Before any intervention is implemented, the nurse should assess whether the intervention is still indicated. In this case, the client's report of voiding makes it all the more essential that the nurse assess whether the client is still retaining urine before inserting the catheter. The nurse should not tell the client the catheter is necessary or unnecessary until after the nurse has completed the assessment and confirmed whether it is necessary.

The nurse is discussing diabetes mellitus with the family members of a client recently diagnosed. To promote the health of the family members, what would be the most important information for the nurse to include? a. Medications used to treat diabetes mellitus b. Risk factors for and prevention of diabetes mellitus c. The severity of the client's disease d. The cellular metabolism of glucose

b. Risk factors for and prevention of diabetes mellitus An important nursing function is to enable clients to prevent illness. Because a member of the family has developed diabetes, the other family members are also at risk. The nurse would most appropriately educate the family about the risk factors for and prevention of diabetes mellitus. Knowledge of the medications used to treat diabetes is not necessary at this time and does not help meet the family's needs. The severity of the client's disease does not have an impact on the family's health. Knowledge of the cellular metabolism of glucose is not necessary for the family's health.

The nurse is caring for a postoperative client who is receiving morphine sulfate for pain management. The nurse obtains the following vital signs: heart rate, 74 beats/min; respiratory rate, 8 breaths/min; blood pressure, 114/68 mm Hg. After reviewing the nursing care plan and physician orders, the nurse administers naloxone. Which would allow the nurse to initiate this action? a. Algorithm b. Standing orders c. Protocol d. Order set

b. Standing orders Standing orders allow the nurse to initiate actions that ordinarily require the order of a physician, such as administering naloxone. An algorithm is a binary decision tree that guides stepwise assessment and intervention for a high-risk subgroup of clients. A protocol is a written plan that details nursing activities to be executed in specific situations. An order set is a preprinted set of provider orders that expedite the provider order process.

The nurse has assessed a client and determined that the client has abnormal breath sounds and low oxygen saturation level. The nurse is performing what type of nursing intervention? a. Supportive b. Surveillance c. Collaborative d. Maintenance

b. Surveillance Surveillance nursing interventions include detecting changes from baseline data and recognizing abnormal responses. Nurses rely on the senses to detect changes, such as observing the appearance and characteristics of clients and hearing by auscultation, pitch, and tone. Nurses use these surveillance activities to determine the current status of clients and changes from previous states. Maintenance nursing interventions involve the nurse assisting the client with performing routine activities of daily living. Supportive nursing measures involve providing basic comfort and emotional care to the client. Collaborative nursing interventions involve cooridination and communication with health care professionals in other fields to meet the client's needs.

The client has a diagnosis of Risk for Injury related to falls. How would the nurse know if the intervention was successful? a. The client calls for assistance to get out of bed. b. The client is free of falls. c. The client is taught safety precautions. d. The client verbalizes risks for injury.

b. The client is free of falls. Interventions for risk diagnoses are directed at prevention. The most appropriate way to evaluate the success of the interventions is to determine if the risk was prevented. The best evaluation criteria would be if the client remained free of falls. The client calling for assistance might prevent a fall, but does not signify that a fall will not occur. Teaching clients safety precautions and having the client verbalize risk for injuries is important but does not necessarily mean that an injury is prevented.

An 87-year-old client has been admitted to the hospital several times in the past few months for exacerbations of chronic obstructive pulmonary disease and elevated blood glucose levels. Which statement by the client could help identify the most likely reason for the changes in the client's health status? a. "My daughter has been staying with me the past few weeks." b. "I asked my neighbors to help me with my yard work." c. "My wife's been gone for about 7 months now." d. "I sort my medication into an organizer every week."

c. "My wife's been gone for about 7 months now." The client's loss may be affecting how well the client is able to provide self-care. The client may be depressed and questioning the benefits of the health care regimen, or the client may have depended on the wife to help with health care and no longer has the ability to take care of himself. Assessment of the client allows the nurse to alter the plan of care to meet the client's needs. The statements concerning having a family member staying with the client, having help with the yard work, and sorting medications into an organizer all indicate factors that would improve the client's ability to provide self-care, not decrease it.

A client requires a change and reapplication of a colostomy bag. The nurse has never changed an ostomy bag before. What is the nurse's best course of action? a. Ask the client how the bag is changed. b. Read the policy and procedure manual. c. Ask a skilled nurse to assist with the procedure. d. Determine the necessity of the bag change.

c. Ask a skilled nurse to assist with the procedure. Professional nurses should only undertake tasks that they have been properly trained to perform. Because the nurse has no experience in changing an ostomy bag, it would be most appropriate to have the assistance of an experienced nurse. It would be inappropriate to ask the client how the bag is changed. The client is relying on the nurse to have the necessary technical knowledge. Reading the policy and procedure manual alone would not ensure the successful completion of the procedure. The necessity of the ostomy bag change has already been established.

The surgeon is insisting that a client consent to a hysterectomy. The client refuses to make a decision without the consent of the client's spouse. What is the nurse's best course of action? a. Remind the client that the client is responsible for the client's own health care decisions. b. Ask the client whether the client is afraid that the spouse will be angry. c. Ask the surgeon to wait until the client has had a chance to talk to the spouse. d. Inform the surgeon that the nurse will not sign the informed consent form.

c. Ask the surgeon to wait until the client has had a chance to talk to the spouse. It is important to consider the client's wishes, so the nurse should advocate for the client and ask the surgeon to wait until the client has talked to the spouse. Telling the client that the client is responsible for the client's own health care decisions does not respect the client's desire to consult the spouse. The client has not expressed being fearful of the spouse. Informing the surgeon that the nurse will not sign the consent form will not satisfy the client's request.

The home health nurse caring for a client with limited eyesight notes that the client's route to the bathroom is cluttered. What is the most effective way for the nurse to ensure the client's long-term safety? a. Remove all the cluttered objects from the pathway to the client's bathroom. b. Instruct the client about the need to keep the walkway to the bathroom clear. c. Assist the client to identify strategies to promote safety in the home. d. Assign a home health aide to perform housekeeping duties.

c. Assist the client to identify strategies to promote safety in the home. The best way to address safety in the home is to discuss the issue with the client. Because the client has a visual deficit, clutter in the pathway to the bathroom may not be the only hazardous condition in the home. Helping the client identify safety strategies will help the client be more independent and will promote safety in the long run. Removing the cluttered objects would be important for the client's immediate safety, but would not help keep the client safe in the long run. Instructing the client to keep the walkway clear without identifying ways to do it would not keep the client safe. A home health aide could be part of the overall strategy to help protect the client, but the aide will not be present all the time to protect the client.

After instituting interventions to increase oxygenation, the client shows no signs of improvement. What is the nurse's priority action? a. Document the interventions and the result. b. Reassess the client for improvement in 30 minutes. c. Communicate with the physician for additional orders. d. Determine the client's code status in case of an emergency.

c. Communicate with the physician for additional orders. If the nurse's interventions have been ineffective, the physician must be notified of the client's deteriorating status. The physician can direct other medical interventions. Documenting the interventions does not take priority over the client's physiologic needs. Allowing another 30 minutes to elapse before taking action will only cause further deterioration in the client's status. The nurse should know the client's code status when taking over the client's care.

The nurse is caring for a client who is recovering from a cerebrovascular accident. When reviewing the client's orders, the nurse notes that one of the physicians wrote orders to ambulate the client, whereas another physician ordered strict bed rest for the client. How would the nurse most appropriately remedy this conflict? a. Assess the client to determine whether the client is capable of ambulation. b. Instruct the client to ask the physicians for clarifications of instructions. c. Communicate with the physicians to coordinate their orders. d. Collaborate with the physical therapist to determine the client's ability.

c. Communicate with the physicians to coordinate their orders. As coordinator of care, the nurse is responsible for ensuring the continuity of the treatment plan. If conflicts occur in the treatment plan, the nurse should first consult with the physicians who have written the conflicting orders. The nurse may assess the client to determine whether the client is capable of ambulation, but this does not resolve the conflict or determine whether ambulation is in the client's best interest. It is not the client's responsibility to clarify nursing orders. Collaboration with the physical therapist could become part of the plan later, but the physicians' orders have to be clarified first.

A client has terminal cancer and the primary care provider has ordered a diagnostic imaging test. The client does not want the test performed so the nurse agrees to dialogue with the primary care provider on the client's behalf. The nurse's actions are what type of intervention? a. Surveillance b. Supportive c. Coordinating d. Technical

c. Coordinating Coordination involves acting as a client advocate, making referrals for follow-up care, collaborating with other health care team members, and ensuring that the client's schedule is therapeutic. This is not a surveillance or technical type of intervention. The nurse is being supportive of the client, but advocacy is more closely associated with coordinating types of interventions.

The nurse has prepared to educate a client about caring for a new colostomy. When the nurse begins the instruction, the client states, "I am not ready to deal with this now. I am feeling overwhelmed." What is the nurse's most appropriate action? a. Continue the education and remind the client that it is essential to learn self-care. b. Medicate the client for anxiety and continue the education later. c. Discontinue the education and attempt at another time. d. Discontinue the education and ask the client for permission to teach a family member.

c. Discontinue the education and attempt at another time. The nurse should always perform client education when the client is receptive of the education. The client verbalizes not being ready to learn, so education should be discontinued and continued at another time. Asking for permission to teach a family member does not encourage the client to learn self-care and acquire independence. The client does not need medication for anxiety at this time. This is a normal reaction. It would not be productive to continue the education because the client is not ready to learn.

The nurse is preparing a client for surgery when the client tells the nurse that the client no longer wants to have the surgery. How should the nurse most appropriately respond? a. Review with the client the risks and benefits of surgery. b. Ask the client to discuss the decision with family members. c. Discuss with the client the reasons for declining surgery. d. Notify the physician of the client's refusal.

c. Discuss with the client the reasons for declining surgery. The nurse needs further information before deciding what interventions are necessary, so the most appropriate action is to determine the client's reasons for refusal. Until the information is collected, the nurse cannot decide whether reviewing the risks and benefits of surgery would be effective. It is also premature to ask the client to discuss the decision with family members. It is not appropriate to notify the physician until the assessment is complete.

The nurse in a burn intensive care unit (BICU) is caring for a 3-year-old child who was burned with scalding hot water. The client has burns covering 75% of the body. The client's condition is critical but stable. At 1000, the nurse reassesses the client and finds that the client is agitated and pulling at the endotracheal tube. Which is the nurse's priority intervention for this client at this time? a. Providing medication for agitation b. Repositioning to prevent pressure injuries c. Ensuring that the endotracheal tube is secure d. Changing the dressing to prevent infection

c. Ensuring that the endotracheal tube is secure The ABCs (airway, breathing, and circulation) are always top priority in client care. In this example, ensuring that the client maintains a patent airway will always be top priority. Each of these nursing tasks is important and will need to be accomplished at some point during client care.

The nurse is caring for a client with congestive heart failure. The nurse manager informs the nurse that the client was enrolled in a clinical trial to assess whether a 10-minute walk, 3 times per day, leads to expedited discharge. Which type of evaluation best describes what the researchers are examining? a. Process b. Structure c. Outcome d. Cost-effectiveness

c. Outcome Outcome evaluation focuses on measurable changes in the health status of the client or the end results of nursing care, such as an expedited discharge of the client based on the client recovering more quickly due to an intervention. The focus of a process evaluation is the nature and sequence of activities carried out by nurses implementing the nursing process. A structure evaluation or audit focuses on the environment in which care is provided. Cost-effectiveness is not a type of evaluation identified by the American Nurses Association.

When the nurse enters the room to assess a client's vital signs, the client insists that the nurse perform handwashing. What is the nurse's most appropriate action? a. Inform the client that it is not necessary to wash hands before vital signs. b. Reassure the client that the nurse knows when to perform hand hygiene. c. Praise the client for taking an active role in the client's care. d. Tell the client that gloves are required for this procedure.

c. Praise the client for taking an active role in the client's care. Clients should be empowered to take responsibility for self-care. All clients should be taught that they have the power to question any part of their care. The nurse would appropriately praise the client. It is necessary to wash hands before taking vital signs; gloves are not required for the procedure. Telling the client that the nurse knows when to perform hand hygiene is disrespectful of the client's concern.

Which task would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? a. Secure the client's jewelry before surgery. b. Reassess the client's sacrum for redness when doing a bed bath. c. Provide the client with assistance in transferring to the bedside commode. d. Retrieve a unit of blood from the blood bank.

c. Provide the client with assistance in transferring to the bedside commode. Assisting with toileting is one of the tasks the state board of nursing permits UAPs to perform. UAPs commonly performed this task in health facilities. Each of the other responses demands a level of responsibility that the nurse cannot legally delegate to a UAP.

The nurse is planning instruction on wound care to an adult client. What variables would cause the nurse to alter the education plan? Select all that apply. a. The client is male. b. The client is married. c. The client is blind. d. The client is an architect. e. The client denies the need for education.

c. The client is blind. e. The client denies the need for education. The client's blindness will require the nurse to alter the education plan to fit the client's needs. The education might also require teaching another person to perform the wound care. If the client denies the need for education, attempting to teach the client at this time will be ineffective. The nurse will need to determine why the client denies the need for teaching and address that issue first. The facts that the client is male, married, and an architect do not have any bearing on the instruction.

The registered nurse is working with an unlicensed assistive personnel. Which client should the nurse not delegate to the unlicensed assistive personnel? a. The client who needs vital signs taken following infusion of packed red blood cells. b. The client who requires assistance dressing in preparation for discharge. c. The client with continuous pulse oximetry who requires pharyngeal suctioning. d. The client who is pleasantly confused and requires assistance to the bathroom.

c. The client with continuous pulse oximetry who requires pharyngeal suctioning. The nurse needs to perform the pharyngeal suctioning of the client with continuous pulse oximetry. This client requires the nurse to evaluate the client's response in pulse oximetry to the suctioning. The nurse can delegate the other clients to the unlicensed assistive personnel.

The primary purpose of nursing implementation is to: a. improve the client's postoperative status. b. identify a need for collaborative consults. c. help the client achieve optimal levels of health. d. implement the critical pathway for the client.

c. help the client achieve optimal levels of health. The purpose of the nursing implementation phase is to help the client achieve an optimal level of health. Improving the client's postoperative status and implementing the critical pathway for the client are too narrow to represent the purpose of the implementation phase, although they are purposes of specific interventions that would be implemented during this phase. Identifying the need for collaborative consults is an action the nurse would perform in the planning phase of the nursing process.

While auscultating a client's lung sounds, the nurse notes crackles in the left lower lobe, which were not present at the start of the shift. The nurse is engaged in which type of nursing intervention? a. Educational b. Psychomotor c. Maintenance d. Surveillance

d. Surveillance Surveillance interventions include detecting changes from baseline data and recognizing abnormal response. Nurses rely on the senses to detect changes, such as observing the appearance and characteristics of clients and hearing by auscultation, pitch, and tone. Nurses use these surveillance activities to determine the current status of clients and changes from previous states. Educational interventions require instruction, demonstration, and return demonstration of knowledge or a skill set. Psychomotor interventions involve the nurse physically working with the client. Maintenance interventions involve the nurse assisting the client with performing routine activities of daily living.

A nurse follows set guidelines for administering pain medication to clients in a critical care unit. This nurse's authority to initiate actions that normally require the order or supervision of a physician is termed: a. protocols. b. nursing interventions. c. collaborative orders. d. standing orders.

d. standing orders. Standing orders empower the nurse to initiate actions that ordinarily require the order or supervision of a physician, such as pain medication administration based on specific criteria. Protocols are written plans that detail the nursing activities to be executed in specific situations; these include routine nursing care and standing orders. Nursing interventions refer to care administered by the nurse and can be dependent or independent in nature. Collaborative orders may include suggested care strategies from other health care personnel such as the physical therapist.