Implementation

The nurse performs patient care interventions and documents interventions during which step of the nursing process? Analysis Planning Evaluation Implementation

Implementation Implementation consists of performing patient care interventions and documenting interventions in the patient's chart. WRONG: Analysis The diagnosis, or analysis, step occurs when the nurse identifies a diagnostic label to describe the patient's condition. Planning The planning step occurs when the nurse identifies the interventions to be performed to meet the patient goals. Evaluation Evaluation occurs when the nurse determines the level of goal attainment for the patient.

Which statement describes how nurses use clinical practice guidelines (CPGs) in determining patient care interventions? CPGs provide individualized patient care interventions. The American Nurses Association (ANA) developed CPGs to describe nursing actions. Nurses select interventions that they are qualified and competent to perform by applying CPGs. Nurses apply CPGs to implement standardized interventions for a specific clinical situation.

Nurses apply CPGs to implement standardized interventions for a specific clinical situation. These CPGs are applicable to a variety of health care settings, such as hospitals or long-term care facilities, and focus on a specific clinical situation or problem (e.g., fall prevention), outlining recommended interventions to manage patients experiencing the clinical issue. WRONG: CPGs provide individualized patient care interventions. CPGs provide standardized interventions for specific patient problems. The nurse must also individualize the interventions recommended by the CPGs based on the uniqueness of the patient. The American Nurses Association (ANA) developed CPGs to describe nursing actions. The ANA describes what actions a nurse can take according to the scope of practice, not CPGs. Nurses select interventions that they are qualified and competent to perform by applying CPGs. The scope of practice, not CPGs, defines the interventions that the licensed nurse should be qualified and competent to perform.

Which action is an indirect-care intervention? Informal counseling Patient assessment Activities of daily living (ADLs) Communications with health care providers

Communications with health care providers Indirect-care interventions are those that are performed to benefit the patient but do not involve direct patient contact, such as communicating with other health care providers. WRONG: Informal counseling Direct-care interventions include informal counseling because this involves a face-to-face patient interaction. Patient assessment Direct-care interventions include patient assessment because this involves a face-to-face patient interaction. Activities of daily living (ADLs) Direct-care interventions include ADLs because these involve face-to-face patient interactions.

Which activity reflects an indirect-care type of intervention? Delegation Physical care Reassessment Patient education

Delegation Delegation is an indirect-care intervention because the responsibility for performing the task is transferred to another individual, but the nurse who delegated the task maintains accountability. WRONG: Physical care Physical care interventions require personal contact (direct care) with patients to promote the competent and safe performance of nursing tasks. Reassessment Reassessment is a face-to-face activity that continues throughout all stages of the nursing process. Because patient contact is required, it is a direct-care intervention. Patient education Patient education should be an ongoing process in which the nurse looks for opportunities for teaching each time an interaction with the patient occurs. Because patient teaching involves personal contact, it is a direct-care intervention.

Which statement accurately describes nursing documentation? Missing documentation does not harm patients. The nurse charts only direct-care interventions. Nurses document interventions primarily in the plan of care. Documentation conveys interventions and outcomes to other health care providers.

Documentation conveys interventions and outcomes to other health care providers. Nurses must document interventions to accurately convey patient activities, nursing interventions, and patient outcomes to other health care providers. WRONG: Missing documentation does not harm patients. Missing documentation can harm patients. For example, if a nurse forgets to document that a medication was given, the patient may receive an additional dose of the same medicine. The nurse charts only direct-care interventions. All interventions that are performed by nurses or other health care personnel need to be documented to promote safe, quality care. Nurses document interventions primarily in the plan of care. Nurses commonly document interventions in the patient's electronic health record, plan of care, or standardized flow sheets, depending on agency policy.

Which action occurs after the nurse performs interventions? Determining goals Assessing the patient Resolving the interventions Documenting the interventions

Documenting the interventions After performing patient care, the nurse documents the interventions in the patient's chart. WRONG: Determining goals Goals are determined as part of the planning process. Assessing the patient Assessment is the first step of the nursing process. Reassessment is ongoing throughout the nursing process; however, the nurse should accurately document interventions in a timely fashion to prevent a negative impact on patient outcomes. Reassessment is often done after a designated period, depending on the intervention, such as 30 minutes after medication administration. Resolving the interventions The interventions are not resolved until the evaluation process occurs.

Which activities are independent nursing interventions? Select all that apply. Hand hygiene Patient ambulation Intravenous (IV) fluid management Administration of medications Teaching use of incentive spirometer

Hand hygiene Hand hygiene is an independent nursing intervention. Nurses can initiate this intervention without a health care provider's prescription. Patient ambulation Ambulating the patient is an independent nursing intervention. Nurses can initiate this intervention without a health care provider's prescription. Teaching use of incentive spirometer Patient education regarding the use of an incentive spirometer is an independent nursing intervention. Nurses can initiate this intervention without a health care provider's prescription. WRONG: Intravenous (IV) fluid management IV fluid management is a dependent nursing intervention because IV fluid administration requires a prescription from a health care provider. Administration of medications The administration of medications is a dependent nursing intervention because it requires a prescription from a health care provider.

Which activity occurs during the fourth step of the nursing process? Analyzing patient data Planning the patient's care Implementing interventions Evaluating the patient's response

Implementing interventions Implementation occurs once the nurse has assessed the patient, established the nursing diagnosis, and planned the patient's care. WRONG: Analyzing patient data Patient data are analyzed during the second step of the nursing process. Planning the patient's care The patient's plan of care is developed during the third step of the nursing process. Evaluating the patient's response The interventions are implemented during the fourth step of the nursing process, and then the nurse evaluates their effectiveness during the fifth step.

Which type of intervention benefits the patient but does not involve face-to-face contact with the patient? Direct Indirect Independent Prevention-based

Indirect Indirect-care interventions benefit the patient but do not involve face-to-face contact with the patient. WRONG: Direct Direct-care interventions involve face-to-face contact with the patient. Independent Independent nursing interventions are initiated and conducted by the nurse and may or may not involve face-to-face contact with the patient. Prevention-based Prevention-based interventions are implemented to prevent problems and may or may not involve face-to-face contact with the patient.

Match the type of intervention to its process. Initiated and implemented by the nurse Initiated by a health care provider prescription and conducted by the nurse Initiated by the nurse and executed by other health care team members Collaborative nursing Dependent nursing Independent nursing

Initiated and implemented by the nurse Independent nursing Initiated by a health care provider prescription and conducted by the nurse Dependent nursing Initiated by the nurse and executed by other health care team members Collaborative nursing

Which statement summarizes how the scope of nursing practice influences interventions? It promotes evidence-based practice. It focuses on a specific clinical situation. It describes what actions a nurse can take. It outlines recommended interventions for a patient problem.

It describes what actions a nurse can take. The scope of practice describes the actions a licensed nurse should be qualified and competent to perform WRONG: It promotes evidence-based practice. Clinical practice guidelines promote the transfer of evidence-based practice into the clinical setting to improve patient care outcomes. It focuses on a specific clinical situation. Clinical practice guidelines are applicable to a variety of health care settings, such as hospitals or long-term care facilities, and focus on a specific clinical situation or problem. It outlines recommended interventions for a patient problem. Clinical practice guidelines focus on a specific clinical situation or problem (e.g., fall prevention) and outline recommended interventions to manage patients experiencing the clinical issue.

Match the intervention category to its description. Manages and treats existing issues Avoids patient problems Involves personal contact with the patient Benefits the patient without face-to-face contact Problem-based Direct-care Prevention-oriented Indirect-care

Manages and treats existing issues Problem-based Avoids patient problems Prevention-oriented Involves personal contact with the patient Direct-care Benefits the patient without face-to-face contact Indirect-care

Match the intervention category to the intervention. Monitoring a patient's temperature and skin color for fever Administering antibiotics for infection as prescribed by the health care provider Delegating bathing and dressing to a nursing assistant Independent Collaborative Dependent

Monitoring a patient's temperature and skin color for fever Independent Administering antibiotics for infection as prescribed by the health care provider Dependent Delegating bathing and dressing to a nursing assistant Collaborative

Which intervention category is likely to have the highest priority? Direct-care Independent Problem-oriented Prevention-based

Problem-oriented Problem-oriented interventions are likely to take higher priority because they deal with existing, and potentially immediate, issues. WRONG: Direct-care Direct-care interventions, or those requiring personal contact, may or may not deal with existing or immediate issues. Independent Independent nursing interventions, which are initiated and implemented by the nurse, may or may not deal with existing or immediate issues. Prevention-based Prevention-based interventions may or may not deal with existing or immediate issues. They are designed to prevent problems.

The nurse would categorize interventions according to which formal descriptors? Select all that apply. Priority Purpose Time frame Type of patient contact Who initiates the intervention

Purpose Interventions can be categorized according to purpose (problem-based or prevention-based). Type of patient contact Interventions can be categorized by whether or not they involve personal patient contact (direct or indirect). Who initiates the intervention Interventions can be categorized by who initiates and conducts them (dependent, independent, or collaborative). WRONG: Time frame Interventions are not formally categorized by their time frame. Priority Interventions are not formally categorized by their priority, but problem-based interventions are likely to receive a higher priority because of the presence of active patient problems.

Which activities are direct-care interventions? Select all that apply. Advocacy Research Reassessment Informal counseling Activities of daily living (ADLs

Reassessment Direct-care interventions are conducted through personal contact with the patient. Reassessment is thus a type of direct-care intervention. Informal counseling Direct-care interventions involve personal contact with the patient. Informal counseling is thus an example of a direct-care intervention. Activities of daily living (ADLs) Direct-care interventions require personal or face-to-face contact with the patient. ADLs are assessed in person, so they are an example of a direct-care intervention. WRONG: Advocacy Advocacy is an indirect-care intervention because personal contact with the patient is not required. Nurses act as patient advocates, promoting the best interests of the patient and managing care needed to improve patient outcomes. Research Research is an indirect-care intervention because the nurse does not have to interact personally with the patient. Nursing research contributes new knowledge and recognizes best practices for nurses to implement to improve patient care outcomes.

According to the American Nurses Association (ANA) scope of nursing practice, which statements describe an intervention the nurse should be qualified and competent to perform? Select all that apply. The facilitation of healing The prevention of illness and injury The advocacy of patients and families The optimization of patient health and abilities The transfer of evidence-based practice to the clinical setting

The facilitation of healing The ANA scope of practice identifies facilitation of healing as a nursing action. The prevention of illness and injury According to the ANA scope of practice, the prevention of illness and injury determines nursing interventions. The advocacy of patients and families As outlined in the ANA scope of practice, advocacy in the care of individuals, families, groups, communities, and populations guide nursing interventions. The optimization of patient health and abilities According to the ANA scope of practice, nursing interventions enhance the protection, promotion, and optimization of health and abilities. WRONG: The transfer of evidence-based practice to the clinical setting Clinical practice guidelines promote the transfer of evidence-based practice into the clinical setting to improve patient care outcomes.