Ch 16, Interventions, Fundamental of Nursing, 3614

Nurses coordinate many types of interventions when initiating a care plan. How are nursing interventions categorized?

-By purpose. -By who initiates or conducts them. -By type of patient contact.

Which are the indirect-care interventions?

-Collaboration. -Referrals. -Delegation.

Which are the direct-care interventions?

-Informal counseling. -ADLs. -Reassessment.

The nurse is caring for a post-operative patient. Which intervention is considered to be prevention-oriented?

-Post-operative ambulation.

The nurse is caring for a postoperative patient in the medical-surgical unit. Which interventions are considered to be independent nursing interventions?

-Use of incentive spirometer. -Hand hygiene. -Ambulating the patient.

Collaborative nursing interventions

Collaborative nursing interventions are initiated by the nurse or through consult with other healthcare team members, and conducted by other healthcare team members.

Which is an example of an indirect-care intervention?

Communication with providers.

Which statement about indirect-care interventions is true?

Delegation is an indirect-care intervention.

Dependent nursing interventions

Dependent nursing interventions are initiated by a provider in the form of an order, and conducted by the nurse.

Which statement about nursing documentation is true?

Documentation conveys interventions and outcomes to other care providers.

The nurse is caring for a patient receiving anticoagulant therapy. Which intervention is considered to be a dependent intervention?

Holding dose due to abnormal lab value.

The nurse has assessed the patient and established a nursing diagnosis of Risk for Impaired Skin Integrity related to immobility. She has determined the interventions are to reposition the patient every two hours and maintain meticulous skin hygiene so that skin integrity is maintained. What is the next step of the nursing process?

Implement the interventions.

The nurse is performing patient care interventions and documenting interventions in the chart. Which step of the nursing process is this?

Implementation.

Independent nursing interventions

Independent nursing interventions are initiated and conducted by the nurse. Independent nursing interventions are interventions that a nurse initiated and carries out independently (without an order from a provider).

Indirect-care interventions

Indirect-care interventions benefit the patient, but do not involve face-to-face contact with the patient.

Nurses conduct change-of-shift reports to communicate assessment findings and outstanding nursing interventions. What type of intervention is this?

Indirect-care.

Match the intervention category with the intervention

Monitoring a patient's temperature and skin color for fever: Independent Administering antipyretic medication for fever as ordered by the provider: Dependent Nursing assistant providing bathing and dressing assistance to a patient.

Which is an example of a collaborative nursing intervention?

Nursing assistant providing range-of-motion on the patient.

Which is a comprehensive, research-based, standardized collection of interventions and activities that nurses often reference when documenting interventions?

Nursing-Interventions Classification (NIC).

The nurse is caring for a post-operative patient following hip repair. Which intervention is considered to be collaborative?

Ambulation with physical therapy.

Direct-care interventions

Direct-care interventions involve direct personal contact with the patient.

The nurse performs patient care interventions according to the individualized care plan. What is the next step in the process?

Document the interventions.

Documentation of interventions is provided to insurance companies for billing and reimbursement. Which Federal guidelines do health care facilities follow when providing patient information to other agencies?

Health Insurance Portability and Accountability Act (HIPAA)

Which is the type of intervention that benefits the patient but does not involve face-to-face contact with the patient?

Indirect care.

Why should the nurse reference Nursing Interventions Classification (NIC) when documenting interventions?

It is useful for clinical documentation.

What are the highest-priority interventions?

Problem-oriented.

What was Nursing Interventions Classification (NIC) developed to do?

Provide a standardized language to document nursing interventions.