Chapter 17 Nursing Diagnosis

A client is admitted to a hospital with a diagnosis of a left femur fracture. The nurse assesses the client's condition and starts with interventions. Which actions are health care provider initiated interventions? Select all that apply. 1 Administering medication 2 Starting an intravenous infusion 3 Explaining the side effects of medications 4 Repositioning client to achieve relief of pain 5 Ordering an X-ray

1-Administering medication 2-Starting an intravenous infusion 5-Ordering an X-ray Health care provider initiated interventions are dependent nursing interventions, or actions that require an order from the primary healthcare provider or another health care professional. Administering a medication, implementing an invasive procedure such as starting an intravenous [IV] infusion, and ordering an X-ray are health care provider initiated interventions. Instructing the client about the side effects of the medication and repositioning the client to achieve pain relief are nurse-initiated interventions and do not require an order from a health care provider. Text Reference - p. 242

An 82-year-old client who resides in a nursing home has the following three nursing diagnoses: risk for fall, impaired physical mobility related to pain, and wandering related to cognitive impairment. The nursing staff identified several goals of care, including "The client will achieve pain relief." Which outcome is related to this goal? 1 Client will express fewer nonverbal signs of discomfort. 2 Client will follow a set care routine. 3 Client will walk correctly using a walker. 4 Client will exit a low bed without falling.

1-Client will express fewer nonverbal signs of discomfort A goal is a broad statement that describes a desired change in a client's condition or behavior. An expected outcome is a measurable criterion to evaluate goal achievement. In this case, the client expressing fewer nonverbal signs of discomfort is a measurable criterion to evaluate pain relief. Text Reference - p. 239

A nurse is caring for a client who has undergone nephrectomy. Which interventions performed by the nurse require an order from another health care professional? Select all that apply. 1 Getting an X-ray of the chest to rule out pulmonary complications 2 Administering an antibiotic to prevent infection 3 Starting an intravenous infusion of normal saline 4 Instructing the client to splint the incision when coughing 5 Instructing the client about the side-effects of the medication

1-Getting an X-ray of the chest on rule out pulmonary complications 2-Administering an antibiotic to prevent infection 3-Starting an intravenous infusion of normal saline 4-Instructing the client to splint the incision when coughing Physician-initiated interventions are dependent nursing interventions or actions that require an order from a physician or other health care professional. These include ordering an X-ray, administering an antibiotic, or starting an intravenous infusion. The nurse can instruct the client to splint the incision when coughing without an order from another health care professional. The nurse can independently instruct the client about the side effects of the medication.

A group of nursing students is being taught independent nursing interventions. Which interventions should be included in the teaching? Select all that apply. 1 Health promotion 2 Starting an intravenous infusion 3 Administration of analgesics 4 Assisting with daily activities 5 Repositioning a client for relief from pain

1-Health promotion 3-Administration of analgesics 4-Assisting with daily activities 5-Repositioning a client for relief from pain Independent nursing interventions pertain to activities of daily living, health education and promotion, and counseling. It also includes activities like repositioning a client to relieve pain. Administration of analgesics and starting an intravenous infusion requires an order from a health care provider. Text Reference - p. 242

In the diagnosis statement "Impaired physical mobility related to incisional pain, evidenced by restricted turning and positioning," which component represents the "etiology or related factor" of the PES format? 1 Incisional pain 2 Impaired physical mobility 3 Evidenced by restricted turning 4 Evidenced by restricted positioning

1-Incisional pain The acronym PES stands for problem, etiology, and symptoms. Incisional pain is "the etiology or related factor" in this diagnosis statement. Impaired physical mobility is "the problem" in this statement. Evidenced by restricted turning and positioning is "the symptom" in this statement. Test-Taking Tip: Remind yourself that the E for etiology in PES is the same as the related factor. The related factor in the diagnosis is what completes the phrase, "related to _________" so that you can easily identify the "E" for etiology in the diagnosis. Text Reference - p. 230

What could be the effect of an incorrect nursing diagnosis? 1 It could affect the quality of client care. 2 It would get corrected automatically in the system. 3 It could affect the client's cost of treatment. 4 It could produce a psychological disorder in the client

1-It could affect the quality of client care. An incorrect nursing diagnosis may affect the quality of client care. Incorrect nursing diagnoses are not corrected automatically in the system. The cost of the client's care is not dependent on the nursing diagnosis. An incorrect nursing diagnosis would not create a psychological disorder in the client. Text Reference - p. 232

What is a health promotion diagnosis, according to the North American Nursing Diagnosis Association International (NANDA)? 1 It describes a person's readiness to enhance specific health behaviors for well-being. 2 It describes human responses to health conditions that may develop in a vulnerable individual. 3 It describes human responses to health conditions that exist in an individual or community. 4 It is associated with a potential response to the health problem and can change by using specific nursing interventions.

1-It describes a person's readiness to enhance specific health behaviors for well-being A health promotion nursing diagnosis is a type of nursing diagnosis that indicates a person's readiness to enhance specific health behaviors for well-being. A human response to health conditions that may develop in a vulnerable individual is a risk nursing diagnosis. A human response to health conditions that exist in an individual or community is an actual nursing diagnosis. A potential response to the health problem that can change by using specific nursing interventions is a related factor. Text Reference - p. 228

The nurse is caring for a client who has sustained a knee injury during a football game. The knee requires arthroplasty. The nurse finds that the client is anxious about his ability to play after the surgery. The nurse selects anxiety as a diagnostic label and clusters its defining characteristics. The goal is: "The client will express acceptance of health status by the day of discharge." Which nurse-initiated interventions should the nurse perform to achieve the goal? Select all that apply. 1 Listen attentively to the client. 2 Refer the client to a psychologist. 3 Use a calm and reassuring approach. 4 Administer medication to reduce the anxiety. 5 Provide factual information regarding the recovery.

1-Listen attentively to the client 3-Use a calm and reassuring approach 5-Provide factual information regarding the recovery Nurse-initiated interventions are independent actions that the nurse initiates. These do not require an order from another health care professional. The nurse-initiated interventions in this case should include listening attentively, using a calm and reassuring approach, and providing factual information regarding recovery. These interventions would help to reduce the client's anxiety. Consulting a psychologist and administering medication require an order from another health care professional

A nurse is teaching nursing students about nursing diagnoses. What does the nurse consider as a nursing diagnosis? Select all that apply. 1 Nausea 2 Pneumonia 3 Acute pain 4 Osteoarthritis 5 Diabetes mellitus

1-Nausea 3-Acute pain Nausea and acute pain are nursing diagnoses. These problems can be easily identified by observing the client's signs and symptoms. They do not require any specific diagnostic test. These problems can be easily treated by the nurse. Pneumonia, osteoarthritis, and diabetes mellitus are medical diagnoses. They require specific diagnostic tests to be confirmed. They are diagnosed by the primary healthcare provider. Text Reference - p. 222

Following an assessment, the nurse is formulating a nursing diagnosis using the PES format. What does the "P" in the acronym PES stand for? 1 Period 2 Problem 3 Prevention 4 Predication

2 Problem-PES format is a nursing diagnosis in three parts. It includes diagnostic label, etiological statement, and symptoms or defining characteristics. The "P" stands for problem, the "E" stands for etiology or related factor, and the "S" stands for symptoms or defining characteristics. The "P" does not stand for period, prevention, or predication. Test-Taking Tip: Tell yourself, "It will be a PROBLEM on the test if I forget what the P of PES means." The P of PES stands for problem! Text Reference - p. 230

Following an initial assessment of a client, the nurse is charting the nursing goals and expected client outcomes. What characteristics of nursing goals and expected outcomes should the nurse keep in mind when charting? Select all that apply. 1 Observable 2 Measurable 3 Client-centered 4 Health care provider-centered 5 No time limit

1-Observable 2-Measurable 3-Client-centered There are seven guidelines that the nurse should keep in mind while writing goals and expected outcomes. They are client-centered goals or outcomes, singular goal or outcome, observable, measureable, time-limited, mutual factors, and realistic. Observable changes occur in physiological findings and in the client's knowledge, perceptions, and behavior. The nurse observes outcomes by directly asking clients about their condition or using assessment skills. The goals and outcomes should be measurable against a set standard. They should also be client-centered, reflecting the client behaviors and responses expected as a result of nursing intervention. The goals and outcomes should not be health care provider centered and there should be a time limit set for ascertaining progressive steps in client care.

The nursing process is an essential component of nursing practice. When using a five-step nursing process, what is the third step? 1 Planning 2 Assessment 3 Implementation 4 Nursing diagnosis

1-Planning Planning is the third step of the nursing process. It involves setting priorities, identifying client-centered goals and expected outcomes, and prescribing individualized nursing interventions. Assessment is the first step, nursing diagnosis is the second, and implementation is the fourth step of nursing process. STUDY TIP: Remember "ANd PIE": Assessment, Nursing diagnosis, Planning, Implementation, and Evaluation are the steps in the five-step nursing process. When you make your list of concepts to study, think of making a grocery list where you add "ANd PIE!" Text Reference - p. 236

A group of nursing students are being taught about the different types of nursing diagnosis. Which ones are examples of health promotion nursing diagnoses? Select all that apply. 1 Readiness for enhanced family coping 2 Acute pain 3 Wandering 4 Readiness for enhanced nutrition 5 Stress urinary incontinence

1-Readiness for enhanced family coping 4-Readiness for enhanced nutrition A health promotion nursing diagnosis is a clinical judgment. The clinical judgment can be of a person's, family's, or community's motivation, desire, and readiness to increase wellbeing and actualize human health potential. It is expressed in their readiness to enhance specific health behaviors such as nutrition and exercise. Acute pain, wandering, and stress urinary incontinence are examples of actual nursing diagnosis. Actual nursing diagnoses are human responses to health conditions or life processes pg.228

A nurse is caring for a client who has undergone nephrectomy. Which interventions performed by the nurse are independent nursing interventions? Select all that apply. 1 Teaching the client about deep breathing exercises. 2 Starting an intravenous infusion. 3 Administering analgesic medications. 4 Assisting the client in taking a bed bath. 5 Repositioning a client for relief from pain.

1-Teaching the client about deep breathing exercises 4-Assisting the client in taking a bed bath 5-Repositioning a client for relief from pain. Independent nursing interventions are activities that do not need an order from another health care professional. Teaching the client about deep breathing exercises, assisting the client in a bed bath, and repositioning the client can be performed independently by the nurse. Administration of analgesic and intravenous infusion require an order from a health care professional.

Which finding would indicate acute pain in a patient? 1 The patient has dilated pupils. 2 The patient has absence of fatigue signs. 3 The patient does not show fear of reinjury. 4 The patient does not show signs of depression

1-The patient has dilated pupils Pupil dilation is a characteristic of acute pain. Therefore, if the patient has dilated pupils, it supports the nurse's conclusion. The defining characteristics for chronic pain are signs of fatigue, fear of reinjury, and depression. The patient does not show these signs; therefore, the patient does not have chronic pain. Text Reference - p. 227

A nurse is caring for a football player hospitalized for ankle surgery. The client communicates properly during the interview. The nurse finds a quiver in the client's voice as he expresses his worry about not being able to play. The nurse observes that the client has fidgety hands and legs. The nurse concludes that the client is uncertain about his ability to play postsurgery. Which data cluster helps the nurse choose anxiety as a diagnosis? Select all that apply. 1 Verbal expression of worry 2 Fidgety hands and legs 3 Quiver in the client's voice while talking 4 Impending ankle surgery 5 Hospitalization

1-Verbal expression of worry 2-Fidgety hands and legs 3-Quiver in the client's voice while talking The client's verbal expression of worry, fidgety hands and legs, and a quiver in voice are defining characteristics. A defining characteristic is a clinical criterion that is observable and verifiable. These data support the diagnosis of anxiety. Impending ankle surgery and hospitalization are related factors and do not define the data cluster, which is a set of signs or symptoms gathered during assessment and grouped together in a logical way. Text Reference - p. 229

The nurse completed the following assessment: 63-year-old female client has had abdominal pain for 6 days. She reports not having a bowel movement for 4 days, whereas she normally has a bowel movement every 2 to 3 days. She has not been hospitalized in the past. Her abdomen is distended. She reports being anxious about upcoming tests. Her temperature was 37° C, pulse 82 and regular, blood pressure 128/72. Which of the following data form a cluster, showing a relevant pattern? Select all that apply. 1 Vital sign results 2 Abdominal distention 3 Age of client 4 Change in bowel elimination pattern 5 Abdominal pain 6 No past history of hospitalization

2-Abdominal distention 4-Change In bowel elimination pattern 5-Abdominal pain The presence of abdominal pain, distention, and a change in bowel elimination pattern forms a cluster , suggesting an elimination problem. Text Reference - p. 226

A client is diagnosed with urinary stress incontinence. The nurse identifies it as which type of diagnosis? 1 Risk diagnosis 2 Actual diagnosis 3 Chronic diagnosis 4 Health promotion diagnosis

2-Actual diagnosis Urinary stress incontinence is an actual diagnosis. Actual diagnosis describes human responses to health conditions or life processes that exist in an individual, family, or community. A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. A health promotion nursing diagnosis is a clinical judgment of a person's, family's, or community's motivation, desire, and readiness to increase well-being. Chronic diagnosis is not a type of nursing diagnosis. Text Reference - p. 227

Priority setting is helpful to solve collaborative problems. What is a high level priority? 1 One related to non-emergent needs of the clients 2 One related to life-threatening needs of the clients 3 One focused on the client's long-term health care needs 4 One related only to the physiological diagnosis

2-One related to life-threatening needs of the clients Priority setting is helpful to sequence nursing interventions to solve collaborative problems. It is related to life-threatening needs of the clients. If life-threatening needs are untreated, the client may be harmed. Priority setting is related to the emergent needs of the clients. Focusing on the client's long- term health care needs is considered a low-level priority. High-level priorities are not only limited to physiological diagnosis, but also psychological diagnosis.

Following an assessment, a nurse is formulating a nursing diagnosis using the PES format. What does the "S" in PES stand for? 1 Situation 2 Symptoms 3 Sensitivity 4 Separation of data

2-Symptoms PES is a three-part nursing diagnosis format. It includes diagnostic label, etiological statement, and symptoms or defining characteristics. The "P" stands for problem, the "E" stands for etiology or related factors, and the "S" stands for symptoms or defining characteristics. The "S" does not stand for situation, sensitivity, or separation of data.

A nurse is caring for a client who has sustained a knee injury during a football game. The knee requires arthroplasty. The nurse finds that the client is anxious about his ability to play after the surgery. The nurse selects anxiety as a diagnostic label and clusters its defining characteristics. The goal the nurse sets is: "The client will express acceptance of health status by the day of discharge." Which interventions performed by the nurse are collaborative interventions? Select all that apply. 1 Preparing the client for diagnostic tests 2 Administering medications to the client 3 Consulting with a physiotherapist for postoperative exercises 4 Consulting with the home health department to ensure the client will have home health visits 5 Consulting with the unit discharge coordinator who will help the client plan for his return home

3-Consulting with a physiotherapist for postoperative exercises 4-Consulting with the home health department to ensure the client will have home health visits 5-Consulting with the unit discharge coordinator who will help the client plan for his return home Collaborative interventions require the combined knowledge, skill, and expertise of multiple health care professionals. In this case, the interventions should include consulting with a physiotherapist, the home health department, and the unit discharge coordinator to implement the appropriate therapies for the client. Preparing the client for diagnostic tests and administering medication are physician-initiated interventions.

Which nursing intervention is most beneficial to a patient who has impaired mobility due to a musculoskeletal injury in both legs? 1 Immobilizing both legs of the patient for few days 2 Including high-fiber food in the diet plan of the patient 3 Encouraging active range-of-motion exercises every 2 hours 4 Instructing the patient to avoid the use of the three-point crutch gait

3-Encouraging active range-of-motion exercises every 2 hours Active range-of-motion exercises can decrease the risk of immobility in the patient with musculoskeletal injury of both legs. Therefore, the patient with musculoskeletal injury should perform active range-of-motion exercises every 2 hours. Immobilizing both legs of the patient can further impair the physical mobility in the patient. High-fiber food can prevent the risk of constipation in the patient but does not reduce the risk of impaired mobility. The patient should be instructed to use the three-point crutch gait.

The nursing diagnosis, "readiness for enhanced communication," is an example of a(n): 1 Risk nursing diagnosis. 2 Actual nursing diagnosis. 3 Health promotion nursing diagnosis 4 Wellness nursing diagnosis.

3-Health promotion nursing diagnosis A client's readiness for enhanced communication is an example of a health-promotion diagnosis because it implies the client's motivation and desire to strengthen his health.

What is the benefit of an accurate nursing diagnosis? 1 It decreases the side effects of medications. 2 It reduces the cost of treatment to the client. 3 It helps ensure effective and efficient nursing interventions. 4 It prevents further assessment.

3-It helps ensure effective and efficient nursing interventions An accurate nursing diagnosis helps ensure effective and efficient nursing interventions. Selecting the correct nursing diagnosis is based on proper assessment of the client and proper analysis of the health problem. It enhances the nursing care provided to the client. It does not decrease the side effects of the medicines or the cost of treatment. Further assessment after the nursing diagnosis is essential to evaluate the effectiveness of activities performed. Text Reference - p. 222

Which outcome allows you to measure a client's response to care more precisely? 1 The client's wound will appear normal within 3 days. 2 The client's wound will have less drainage within 72 hours. 3 The client's wound will reduce in size to less than 4 cm (1.5 inches) by day 4. 4 The client's wound will heal without redness or drainage by day 4.

3-The client's wound will reduce in size to less than 4 cm (1.5 inches) by day 4. An outcome must have terms describing quality, quantity, frequency, length, or weight to allow for precise measurement. Identifying a specific wound size indicates a degree of healing. The client's wound "will appear normal" and "will have less drainage" are vague and not measurable. "The client's wound will heal without redness or drainage by day 4" has more than one outcome.

A nurse is assessing the clients on the unit. The nurse identifies some collaborative problems among the clients. What are some examples of collaborative problems? Select all that apply. 1 Cold 2 Nausea 3 Paralysis 4 Hemorrhage 5 Wound infection

3-paralysis 4-Hemorrhage 5-Wound infection Collaborative problems are actual or potential physiological complications that the nurse can monitor to detect the onset of changes in the client's status. Hemorrhage, paralysis, and wound infections are collaborative problems. These problems require nursing and monitoring. Cold and nausea are not collaborative problems as they do not lead to multiple complications.

A goal describes a desired change in a client's condition or behavior. For which client is a short-term goal appropriate? 1 A client who has undergone cancer therapy 2 A client who requires rehabilitation post amputation 3 A client who is diagnosed with diabetic neuropathy 4 A client who has acute pain related to incisional trauma

4-A client who has acute pain related to incisional trauma A short-term goal is an objective behavior or response that you expect a client to achieve in a short time, usually less than a week. A client who has acute pain related to incisional trauma requires short-term goals for pain relief. A client who requires amputation rehabilitation will have long-term goals for rehabilitation. A client who has undergone cancer therapy and a client who has diagnosed diabetic neuropathy require a long-term goal as these are chronic problems. Text Reference - p. 239

A client has the nursing diagnosis of nausea. The nurse develops a care plan with the following interventions. Which is an example of a collaborative intervention? 1 Provide frequent mouth care. 2 Maintain intravenous (IV) infusion at 100 mL/hr. 3 Administer prochlorperazine (Compazine) via rectal suppository. 4 Consult with dietitian on initial foods to offer client. 5 Control aversive odors or unpleasant visual stimulation that triggers nausea.

4-Consult with dietitian on initial foods to offer client

What is the measurable criterion used to evaluate goal achievement? 1 Consultation 2 Critical thinking 3 Communication 4 Expected outcome

4-Expected outcome

Which nursing intervention should the nurse omit while caring for a patient who was recently diagnosed with cancer? 1 Preparing a proper diet plan for the patient and completing education 2 Teaching pain relieving methods to the patient and verbalizing understanding 3 Elevating the edematous extremity of the patient to help with swelling 4 Initiating the cancer treatment without a provider's order

4-Initiating the cancer treatment without a provider's order The nurse should not initiate the treatment for the patient with cancer without written or verbal orders from the primary health care provider. Interventions such as elevating the edematous extremity of the patient, preparing a proper diet plan, and teaching pain relieving methods to the patient can be initiated directly by the nurse and are good choices.

What should the nurse focus on when formulating a nursing diagnosis? 1 Disease 2 Complication 3 Physiological event 4 Potential response to a health problem

4-Potential response to a health problem A nursing diagnosis focuses on a client's potential response to a health problem. A nursing diagnosis provides a basis for selecting, planning, and implementing interventions. Diseases, complications, and physiological events are not the focus of formulating the nursing diagnosis. These components are part of a medical diagnosis. Text Reference - p. 227

How should the nurse document the expected outcome statement after assessing the apical pulse in a patient? 1 The patient has a normal apical pulse. 2 The patient's apical pulse values are stable. 3 The patient has acceptable apical pulse values. 4 The patient's apical pulse is 80 beats per minute.

4-The patient's apical pulse is 80 beats per minute. The nurse should use terms describing quality, quantity, frequency, length, or weight in the expected outcome statement; this helps to evaluate outcomes accurately. Therefore, the nurse should document that the patient's apical pulse is 80 beats per minute after assessing. Vague terms result in guesswork in evaluating the patient's response to care. The words such as normal, stable, and acceptable are vague terms. Therefore, the nurse should avoid using these terms while documenting expected outcome statements

What should the nurse do if he or she finds that a patient is anxious due to a job loss? Select all that apply. A Encourage patient to continue exercise routine. B Instruct the patient to remain alone for few days. C Instruct the family to limit conversation with the patient. D Ensure communication between the patient and social worker. E Administer intravenous fluids and electrolytes to the patient

A-Encourage patient to continue exercise routine D-Ensure communication between the patient and social worker The patient who is anxious due to a job loss requires counseling on health promotion tips. Therefore, the nurse should encourage the patient to continue with exercises to help the patient reduce anxiety. Social workers give counseling regarding a job; therefore, the nurse should encourage communication between the patient and social worker. Remaining alone can further increase the risk of anxiety in the patient. Limiting conversation can keep the patient in emotional distress. Intravenous fluids and electrolytes do not reduce anxiety in the patient. Therefore, there is no need of administering intravenous fluids and electrolytes to the patient in this situation. Text Reference - p. 229

Which patient-related factors fall under health promotion nursing diagnosis? Select all that apply. A The patient follows poor hygiene measures. B The patient is willing to consume nutritious foods. C The patient shows impaired interaction with society. D The patient is ready to enhance his or her coping skills. E The patient shows readiness to perform regular exercises.

B-The patient is willing to consume nutritious foods D-The patient is ready to enhance his or her coping skills E-The patient shows readiness to perform regular exercises. Health promotion nursing diagnosis is a clinical judgment of a patient's motivation, desire, and readiness to increase well-being. While performing health promotion nursing diagnoses, the nurse should focus on the patient's readiness to eat nutritious food. While performing health promotion nursing diagnosis, the nurse should assess the patient's readiness to enhance coping skills and to perform regular exercise. While performing risk nursing diagnosis, the nurse should focus on poor hygiene measures of the patient. While performing actual nursing diagnosis, the nurse should focus on the patient's social interaction ability. Text Reference - p. 228

Which patient-related factors fall under health promotion nursing diagnosis? Select all that apply. A The patient follows poor hygiene measures. B The patient is willing to consume nutritious foods. C The patient shows impaired interaction with society. D The patient is ready to enhance his or her coping skills. E The patient shows readiness to perform regular exercises

B-The patient is willing to consume nutritious foods. D-The patient is ready to enhance his or her coping skills E-The patient shows readiness to perform regular exercises Health promotion nursing diagnosis is a clinical judgment of a patient's motivation, desire, and readiness to increase well-being. While performing health promotion nursing diagnoses, the nurse should focus on the patient's readiness to eat nutritious food. While performing health promotion nursing diagnosis, the nurse should assess the patient's readiness to enhance coping skills and to perform regular exercise. While performing risk nursing diagnosis, the nurse should focus on poor hygiene measures of the patient. While performing actual nursing diagnosis, the nurse should focus on the patient's social interaction ability. Text Reference - p. 228

Which nursing interventions fall under the category of nurse-initiated interventions? Select all that apply. A Inserting a Foley catheter B Starting an intravenous infusion C Elevating an edematous extremity D Repositioning the patient to relieve pain E Informing about the side effects of medications

C-Elevating an edematous extremity D-Repositioning the patient to relieve pain E-Informing about the side effects of medications Nurse-initiated interventions do not require any written or verbal orders from the primary health care provider. Interventions such as elevating the edematous extremity of the patient, repositioning the patient to achieve pain relief, and informing about the side effects of medications can be initiated directly by the nurse and do not require any order from the primary health care provider. Initiating interventions such as inserting a Foley catheter or an intravenous infusion requires written or verbal orders from the health care provider. Text Reference - p. 242