Chapter 19 Implementing Nursing Care

The nurse is caring for a 79-year-old patient. The patient has had diabetes for 10 years and comes to the hospital for regular checkups. The nurse finds that the patient has developed a nonhealing wound on the left foot. The nurse is dressing the patient's wound. While performing the dressing, the nurse is unsure about the dilution of the antiseptic solution to be used. What should the nurse do? 1 Refer to the clinical practice protocol. 2 Ask a colleague who knows about it. 3 Skip the use of antiseptic and continue dressing the wound. 4 Wait until the health care provider makes rounds.

1 Clinical practice protocol is a set of guidelines that helps healthcare providers to make decisions about appropriate health care. Therefore, the nurse should refer to the clinical practice protocol to know the accurate dilution of the antiseptic solution. Asking her colleague is not reliable. Skipping the use of antiseptic is not ethical, and waiting for the healthcare provider is not necessary in this case.

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

1 Indirect care activities are those that the nurse performs without coming into direct contact with the patient. These activities are not necessarily performed on the patient but are meant for the betterment of the patients. Infection control is an example of indirect care. Counseling the patient, administering medication, and performing diagnostic tests involve direct contact between the nurse and the patient. These are examples of direct care.

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

1 Indirect interventions are those that are performed by not having direct contact with the patient. Managing the patient's environment involves safety and infection control, which have an indirect impact on the patient's health. The administration of medication, insertion of intravenous infusion, and counseling the patient are all part of direct interventions.

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

1, 2, 3 An adverse reaction is an undesirable effect following administration of a medication. The reaction should be recorded for further reference. The nurse should stop the medication to prevent worsening of the reaction. The healthcare provider should be notified so that remedial measures can be taken. Starting an oral antiemetic drug without the healthcare provider's order is unethical. Administering the drug after the reaction subsides may worsen the reaction.

Expected patient outcomes are important components of a nursing care plan. What are the principles of care coordination that help to achieve the patient's desired outcomes? Select all that apply. 1 Organizational skills 2 Good time management 3 Appropriate use of resources 4 Providing the single best intervention 5 Avoiding prioritization of patient needs

1, 2, 3 It is important to apply principles of care coordination such as organization skills, good time management, and appropriate use of resources. It helps to deliver interventions effectively and meet desired outcomes. Most clinical situations require multiple interventions to achieve selected outcomes. Setting priorities is critical to successful implementation.

The nurse is explaining the levels of prevention to a group of nursing students. Which information should the nurse include? Select all that apply. 1 Primary prevention involves immunizations, health education programs, nutrition, and physical activities. 2 Secondary prevention involves early diagnosis and prompt treatment. 3 Tertiary prevention involves minimizing the effects of long-term illness or disability, including rehabilitation. 4 Secondary prevention focuses on people who are experiencing health problems or illnesses. 5 Tertiary prevention focuses on people who are at risk for developing complications or worsening conditions.

1, 2, 3, 4 Primary preventions involve immunizations, health education programs, nutrition, and physical activities. Secondary prevention involves early diagnosis and prompt treatment. Tertiary prevention involves minimizing the effects of long-term illness or disability, including rehabilitation. The secondary prevention focuses on people who are experiencing health problems or illnesses. The secondary prevention also involves people who are at risk for developing complications or worsening conditions.

The nurse is reviewing and revising an existing nursing care plan. Which actions should the nurse perform when revising a nursing care plan? Select all that apply. 1 Revise the nursing diagnoses. 2 Add new data with appropriate dates. 3 Maintain irrelevant nursing diagnoses. 4 Choose the method of evaluation for assessing patient outcomes. 5 Continue the old, specific interventions for new nursing diagnoses.

1, 2, 4 The nursing diagnoses should be appropriate for the patient's current status, so any changes in diagnoses should be updated. New data should be recorded with the appropriate dates to inform other healthcare team members about the type of change and the time of change. Choosing the method of evaluation is necessary to assess the success of the new methods in improving patient outcomes. Any nursing diagnoses that are not relevant should be deleted, and new diagnoses should be mentioned with new dates. Specific interventions should be appropriate for the new nursing diagnoses and the necessary changes should be made accordingly.

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

1, 2, 4 When making decisions about implementation, reviewing all possible interventions and consequences and determining the probability of consequences are necessary steps. The nurse is responsible for having the necessary knowledge and clinical competency to perform an intervention, but this is not part of the decision making involved. Evaluation is a separate part of the nursing process.

A patient is admitted to the hospital for abdominal pain. The patient is instructed not to eat or drink anything by mouth for the next 24 hours. The patient also complains of nausea and vomiting. The healthcare provider orders an antiemetic drug for the patient. The antiemetic drug is new on the market and the nurse is not sure how to administer it. What should the nurse do? Select all that apply. 1 Ask the pharmacist for help. 2 Consult another nurse for assistance and guidance regarding the drug. 3 Administer a different antiemetic drug. 4 Look up the medication in a drug book. 5 Request that the healthcare provider administer oral medication.

1, 2, 4 When the nurse does not know about a certain medication or how to administer it, the nurse should ask the pharmacist for help. The nurse can also consult another experienced nurse for help and guidance. The nurse can look up the medication in a drug book for more information. The nurse cannot administer another antiemetic drug without the healthcare provider's orders. The patient is instructed to be NPO; therefore, oral medications would not be administered.

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

1, 2, 4, 5 During counseling, the nurse must counsel the patient to accept the change in health status. Once the change has been accepted, the patient can start taking care of himself or herself. Counseling involves emotional, psychological, intellectual, and spiritual support, not just emotional and psychological support. Counseling helps in managing stress and developing interpersonal relationships. A patient and family who need nursing counseling have normal adjustment difficulties and may be upset or frustrated, but they are not always psychologically disabled.

Some interventions are direct, and some are indirect. Identify all of the indirect nursing interventions. Select all that apply. 1 The nurse checks the monthly performance improvement report on fall occurrences on a unit. 2 The nurse discusses with the patient exercise restrictions to follow upon return home. 3 The nurse consults with a dietitian about a patient's therapeutic diet food choices. 4 The nurse administers a tube feeding. 5 The nurse assists a colleague in applying a complex dressing to a patient's wound.

1, 3 Direct activities are those that nurses perform through patient interactions. Indirect care measures include nurse actions aimed at management of the patient care environment and interdisciplinary collaborative actions that support the effectiveness of direct care interventions.

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

1, 3, 5 You require additional knowledge and skills in situations in which you are less experienced. Collecting the necessary equipment and considering potential consequences are actions needed for any procedure.

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

2 The double-contrast barium enema test is usually performed in a patient with Crohn's disease. The patient with Crohn's disease often experiences constipation. The barium enema has the potential side effect of fecal impaction in the patient. Therefore, to prevent the complications of constipation, the nurse should increase fluid in the diet for the patient to ensure easy bowel movements. Potato chips would not help to regulate the patient's bowels. A fiber-rich diet will help relieve constipation. Removal of fiber rich food from the diet plan will increase the likelihood of constipation. Iron supplements can further increase the likelihood of constipation. Therefore, the nurse should not give iron supplements to the patient after the test.

The nurse checks a physician's order and notes that a new medication was ordered. The nurse is unfamiliar with the medication. The nurse's colleague explains that the medication is an anticoagulant used for postoperative patients with risk for blood clots. Before giving the medication, what is the nurse's best action? 1 Consult with the colleague before giving the medication. 2 Consult with a pharmacist to obtain knowledge about the purpose of the drug, the action, and the potential side effects. 3 Ask the colleague to administer the medication to her patient. 4 Administer the medication as prescribed and on time.

2 When the nurse performs a new or unfamiliar procedure, such as giving a new medication, it is important to assess personal competency and determine if new knowledge or assistance is needed. The nurse's best action is to check with the pharmacist about the medication. Having another nurse check the dosage is appropriate if the nurse is still uncertain about the medication. Once the nurse feels prepared, the medication is administered as prescribed. You never ask a colleague to give a medication to a patient to whom you are assigned.

In which of the examples is the nurse applying critical thinking skills when preparing to insert an intravenous (IV) catheter? Select all that apply. 1 Following the procedural guideline for IV insertion 2 Seeking necessary knowledge about the steps of the procedure from a more experienced nurse 3 Showing confidence in performing the correct IV insertion technique 4 Being certain that the IV dressing covers the IV site completely 5 Properly cleaning the site before insertion

2, 3 Seeking necessary knowledge about the steps of the procedure shows humility. The nurse recognizes the need for clarification from a senior colleague. Another example of a critical thinking skill is showing confidence. In this case, confidently inserting an IV line allows the nurse to convey expertise and a sense of calm, leading the patient to trust the nurse. Following policy and procedure is an example of following standards of care, not of a critical thinking skill. Making sure that the dressing is covered is a step in following good standards of IV care but is not a critical thinking skill.

Which actions should the nurse perform when asked to administer a procedure with which she is unfamiliar? Select all that apply. 1 Take shortcuts if assistance is unavailable. 2 Collect all equipment necessary for the procedure. 3 Seek information about the procedure. 4 Get help from a nurse experienced in the procedure. 5 Begin the procedure without seeking assistance.

2, 3, 4 Collecting all equipment necessary for the procedure is a part of preparation and will help prevent last-minute hassles. Information about the procedure can be found by referring to medical literature or consulting experienced nurses and clinical specialists. A nurse who is experienced in the procedure can help guide a nurse who is unfamiliar with it. The nurse should avoid taking shortcuts if assistance is unavailable, because there is a risk of injury to the nurse and the patient. Similarly, a nurse who is unfamiliar with a procedure should not perform it without seeking assistance, because this may injure the patient or nurse.

The nurse enters a patient's room and finds that the patient was incontinent of liquid stool. The patient has recurrent redness in the perineal area, and there is concern that he is developing a pressure ulcer. The nurse cleanses the patient, inspects the skin, and applies a skin barrier ointment to the perineal area. She calls the ostomy and wound care specialist and asks that he visit the patient to recommend skin care measures. Which options describe the nurse's actions? Select all that apply. 1 The application of the skin barrier is a dependent care measure. 2 The call to the ostomy and wound care specialist is an indirect care measure. 3 The cleansing of the skin is a direct care measure. 4 The application of the skin barrier is a direct care measure. 5 The cleansing of the skin is a dependent care measure

2, 3, 4 The call to the ostomy and wound care specialist is an indirect care measure involving collaborative care. Cleansing the skin is an independent, direct care measure. Applying the skin barrier is an independent nursing measure involving direct care.

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

2, 3, 5 Before any procedure, the nurse should determine which equipment and supplies will be necessary, but he or she should also keep some extra supplies handy so that they are available in case of need. The nurse should also ensure that all the equipment is in working condition and safe to use. The extra supplies should remain sealed unless needed because this helps to reduce costs. The equipment must be properly placed so that it is handy for healthcare personnel during the procedure. The equipment is not kept close to patients.

The nurse is preparing a nursing care plan. What implementation activities play a role in helping to achieve the patient's expected outcomes? Select all that apply. 1 Reassessing the patient 2 Focusing on preventative measures 3 Organizing resources and care delivery 4 Counseling and motivating the patient 5 Reviewing and revising the existing nursing care plan

2, 4 Five preparatory activities of nursing implementation include reassessing the patient, reviewing and revising the existing nursing care plan, organizing resources and care delivery, anticipating and preventing complications, and implementing nursing interventions. Focusing on preventive measures, and counseling and motivating the patient are implementation factors.

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

3 A common method for administering physical care techniques appropriately includes protecting you and your patients from injury, which involves safe patient handling. Transferring a patient is a direct care measure. Organization is an aspect of physical care but not an example of this nurse's action. Although meeting patient needs is important, it is not a physical care technique.

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

3 An adverse reaction is any unintended harmful action of any medication or therapeutic procedure. The development of hives is an adverse reaction to penicillin. Aggravation is an increase in the severity of existing symptoms. Amelioration is a decrease in the severity of existing symptoms. A therapeutic effect is the expected outcome of relief of symptoms.

The nurse is talking with a patient who is visiting a neighborhood health clinic. The patient came to the clinic for repeated symptoms of a sinus infection. During their discussion, the nurse checks the patient's medical record and realizes that he is due for a tetanus shot. Administering the shot is an example of what type of preventative intervention? 1 Tertiary 2 Direct care 3 Primary 4 Secondary

3 An immunization is an example of a primary prevention aimed at health promotion. Tertiary prevention involves minimizing the effects of long-term illness or disability, including rehabilitation measures. Direct care refers to meeting the patient's physical needs. Secondary prevention focuses on people who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. It includes screening techniques and treating early stages of disease.

The nurse works in collaboration with a physiotherapist to help aid the ambulatory functions of a patient who suffered from a motor vehicle accident. What is this level of prevention called? 1 Indirect care 2 Primary prevention 3 Tertiary prevention 4 Secondary prevention

3 Tertiary prevention involves minimizing the adverse effects of any disease or disability. This also includes rehabilitation. Indirect care is a process by which there is no direct contact between nurse and patient, but the nurse works for the benefit of the patient. Primary prevention aims at health promotion and taking preventive steps before the disease or problem starts. Secondary prevention refers to measures taken for people who are suffering from a disease or are at risk for developing complications.

Which statement made by the student nurse indicates effective learning about caring for a patient who is on an enteral feeding tube? 1 "I should assist the patient into a supine position." 2 "I should check the position of the tube once a day." 3 "I should position the patient in high-Fowler's position." 4 "I should introduce solid foods through the feeding tube."

3 The high-Fowler's position reduces the risk of aspiration in patients who are on enteral tube feeding. Therefore, the student nurse should position the patient with the feeding tube in a high-Fowler's position. The supine position increases the likelihood of aspiration in the patient. Therefore, the student nurse should not position the patient in a supine position. The student nurse should frequently check the proper positioning of the tube, not just once a day. Solid foods occlude the tube and make food difficult to pass through the feeding tube. Therefore, the student nurse should introduce blended or liquid nutrition through the feeding tube.

During the implementation step of the nursing process, the nurse reviews and revises the nursing plan of care. Place the steps of review and revision in the correct order: 1. Review the care plan. 2. Decide if the nursing interventions remain appropriate. 3. Reassess the patient. 4. Compare assessment findings to validate existing nursing diagnoses.

3, 1, 2, 4 After reassessing a patient, the nurse reviews the care plan and compares assessment data to validate the nursing diagnoses and determine if the nursing interventions remain the most appropriate for the clinical situation. If the patient's status has changed and the nursing diagnosis and related nursing interventions are no longer appropriate, the nurse modifies the nursing care plan.

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

4 A standing order is a printed document that consists of orders for management of clinical problems. A standing order allows the nurse to intervene in the management of patient care (without waiting for directives from the primary healthcare provider) in case of emergencies. A protocol is a set of actions that should be done for a particular condition. Interventions are the actions that the nurse or health care practitioner performs for patient management. A prescription is an individualized order of medication or treatments for a patient with a specific disease.

The nurse has to start an intravenous (IV) line on a patient. The patient has not voided over the past few hours. What should the nurse do before starting the intervention? 1 Sedate the patient and start the IV line. 2 Start the IV line immediately. 3 Sedate the patient and insert a Foley catheter. 4 Wait for the patient to void and then start the IV line

4 Before starting any intervention, the nurse should make sure that the patient is comfortable. The nurse should allow the patient to void urine and then begin the intervention when the patient is comfortable. The intervention should be explained to the patient. Sedating the patient and starting the intervention is not an appropriate nursing practice. There is no need to catheterize if the patient is able to void.

The nurse properly positions a patient and administers an enema solution at the correct rate for the patient's tolerance. What type of implementation skill is this? 1 Interpersonal 2 Cognitive 3 Collaborative 4 Psychomotor

4 Psychomotor skills require the integration of cognitive and motor activities to ensure safe intervention.

While caring for a patient who is receiving the third dose of penicillin therapy, the nurse observes that the patient has developed hives. The nurse immediately stops administering penicillin to the patient and reports to the primary healthcare provider. Which medication does the nurse expect to be prescribed for the patient? 1 Aspirin 2 Lidocaine 3 Morphine 4 Diphenhydramine

4 Some patients with unknown hypersensitivity to penicillin generally develop hives after three doses of penicillin administration. Diphenhydramine is an antihistamine and antipruritic medication that reduces an allergic response. Therefore, the nurse expects diphenhydramine to be prescribed for the patient. Aspirin is an analgesic medication, and does not reduce the allergic response in the patient. Therefore, the nurse does not expect aspirin to be prescribed for the patient. Lidocaine is used to correct the cardiac dysrhythmia in patients but does not reduce the risk of allergic response. Morphine is a narcotic analgesic used for pain.

The nurse administers analgesics to a patient. After an hour, the nurse asks the patient to rate his pain on a pain scale. Which step of the nursing process is the nurse performing? 1 Assessment 2 Diagnosis 3 Implementation 4 Evaluation

4 There are five steps in a nursing process: assessment, diagnosis, planning, implementation, and evaluation. Evaluation involves assessing the effectiveness of the nursing intervention performed. Assessment includes activities such as data collection and interviewing. Diagnosis involves identifying patient needs. Implementation is the stage where the actual nursing interventions are implemented.

Discussing a patient's options in choosing palliative care is an example of: A. Counseling B. Lifesaving measure C. Physical care technique D. Activity of daily living

A

The nurse administers a tube feeding via a patient's nasogastric tube. This is an example of which of the following? A. Physical care technique B. Activity of daily living C. Indirect care measure D. Lifesaving measure

A Administering a tube feeding is an example of a physical care, a direct care technique.

A nurse reviews all possible consequences before helping a patient ambulate such as how the patient ambulated last time; how mobile the patient was before admission to the health care facility; or any current clinical factors affecting the patient's ability to stand, remain balanced, or walk. Which of the following is an example of a nurse's review of this situation? A. Critical thinking B. Managing an adverse event C. Exercising self-discipline D. Time management

A The process of reviewing consequences for a patient is an example of critical thinking and clinical decision making. Managing an adverse event occurs after consequences have occurred. Exercising self-discipline is a critical thinking attitude that guides you in reviewing, modifying, and implementing interventions, which occurs after reviewing consequences. This is not an example of time management.

Before consulting with a physician about a female patient's need for urinary catheterization, the nurse considers the fact that the patient has urinary retention and has been unable to void on her own. The nurse knows that evidence for alternative measures to promote voiding exists, but none has been effective, and that before surgery the patient was voiding normally. This scenario is an example of which implementation skill? A. Cognitive B. Interpersonal C. Psychomotor D. Consultative

A This is an example of a cognitive skill, being used before consultation. It involves critical thinking and decision making so the nurse is able to deliver a relevant nursing intervention.

Which measures does a nurse follow when being asked to perform an unfamiliar procedure? (Select all that apply.) A. Checks scientific literature or policy and procedure B. Reassesses the patient's condition C. Collects all necessary equipment D. Delegates the procedure to a more experienced nurse E. Considers all possible consequences of the procedure

A, B, C, E The nurse does not delegate a procedure to a more experienced nurse. Instead the nurse has another nurse (e.g., staff nurse, faculty, nurse specialist) who has completed the procedure correctly and safely provide assistance and guidance.

A nurse is conferring with another nurse about the care of a patient with a stage II pressure ulcer. The two decide to review the clinical practice guideline of the hospital for pressure ulcer management. The use of a standardized guideline achieves which of the following? (Select all that apply.) A. Makes it quicker and easier for nurses to intervene B. Sets a level of clinical excellence for practice C. Eliminates need to create an individualized care plan for the patient D. Delivers evidence-based interventions for stage II pressure ulcer E. Summarizes the various approaches used for the practice concern or problem

A, B, D Even though a standardized clinical practice guideline offers evidence-based solutions for clinical excellence that nurses can quickly and easily apply in practice, a nurse remains accountable for individualizing even standardized interventions when necessary. A guideline is not a summary of various approaches used by clinicians for a practice issue; it is a summary of the most relevant evidence-based information.

A nurse working on a surgery floor is assigned five patients and has a patient care technician assisting her. Which of the following shows the nurse's understanding and ability to safely delegate to the patient care tech? (Select all that apply.) A. The nurse considers the time available to gather routine vital signs on one patient before checking on a second patient arriving from a diagnostic test. B. Determining what is the patient care technician's current workload. C. The nurse chooses to delegate the measurement of a stable patient's vital signs and not the assessment of the patient arriving from a diagnostic test. D. The nurse reviews with the NAP, newly hired to the floor, her experience in measuring a blood pressure. E The nurse confers with another registered nurse about organizing priorities.

A, C, D A nurse must consider priorities of all assigned patients in deciding which activities should be delegated to NAP. When the decision is between vital signs versus a patient arriving from a diagnostic test, delegation of routine vital signs is appropriate. Ensuring that a NAP is competent to perform an activity is also important. Conferring with another RN about organizing and checking the tech's personal workload are not factors that will assist the RN's own priority setting.

Protecting a violent patient from injury is an example of: A. Counseling B. Lifesaving measure C. Physical care technique D. Activity of daily living

B

During the implementation step of the nursing process, a nurse reviews and revises a patient's plan of care. What is the correct order of steps for this? 1. Modify care plan as needed. 2. Decide if the nursing interventions remain appropriate. 3. Reassess the patient. 4. Compare assessment findings to validate existing nursing diagnoses. A. 2, 1, 3, 4 B. 3, 4, 2, 1 C. 4, 3, 2, 1 D. 3, 4, 1, 2

B Reassessment allows you to review a patient's care plan by validating the nursing diagnoses and determine whether the nursing interventions remain the most appropriate for the clinical situation. When changes are needed, you modify the plan of care.

The nurse enters a patient's room and finds that the patient was incontinent of liquid stool. Because the patient has recurrent redness in the perineal area, the nurse worries about the risk of the patient developing a pressure ulcer. The nurse cleanses the patient, inspects the skin, and applies a skin barrier ointment to the perineal area. The nurse consults the ostomy and wound care nurse specialist for recommended skin care measures. Which of the following correctly describe the nurse's actions? (Select all that apply.) A. The application of the skin barrier is a dependent care measure. B. The call to the ostomy and wound care specialist is an indirect care measure. C. The cleansing of the skin is a direct care measure. D. The application of the skin barrier is an instrumental activity of daily living. E. Inspecting the skin in a direct care activity.

B, C The call to the specialist is a referral and an indirect care measure on the patient's behalf. Cleansing of the skin is an example of direct care. Application of a skin barrier is an independent measure and it is not an instrumental activity of daily living. Inspecting the skin is assessment, not direct care.

A nurse is caring for a complicated patient 3 days in a row. The nurse attends an interdisciplinary conference to discuss the patient's plan of care. In which ways can the nurse develop trust with members of the conference team? (Select all that apply.) A. Is willing to challenge other members' ideas because the nurse disagrees with their rationale B. Shows competence in how to monitor patients' clinical status and inform the physician of critical changes C. Asks a more experienced nurse to attend the conference D. Listens to opinions of members of interdisciplinary team and expresses recommendations for care clearly E. During the meeting focus on similar problems the nurse has had in delivering care to other patients.

B, D Showing competence and exercising effective communication are important for developing trust with interdisciplinary team members. Having another nurse attend the conference who might be less familiar with the patient would not promote trust. Challenging other ideas just because of disagreement does not foster trust. Changing the focus from the patient to the problems of the nurse will not foster trust.

A nurse is visiting a patient in the home and is assessing the patient's adherence to medications. While talking with the family caregiver, the nurse learns that the patient has been missing doses. The nurse wants to perform interventions to improve the patient's adherence. Which of the following will affect how this nurse will make clinical decisions about how to implement care for this patient? (Select all that apply.) A. Reviewing the family caregiver's availability during medication administration times B. Making a judgment of the value of improved adherence for the patient C. Reviewing the number of medications and time each is to be taken D. Determining all consequences associated with the patient missing specific medicines E. Reviewing the therapeutic actions of the medications

B, D Tips for making good clinical decisions during implementation include making a judgment of the value of the consequence to the patient, reviewing all possible consequences associated with each nursing action, determining the probability of all possible consequences, and reviewing the set of all possible nursing interventions for a patient's problems.

Using safe patient handling during positioning of a patient is an example of: A. Counseling B. Lifesaving measure C. Physical care technique D. Activity of daily living

C

What is the importance of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey? A. Measures a nurse's competency in interdisciplinary care B. Measures the number of adverse events in a hospital C. Measures quality of care within hospitals D. Measures referrals to a health care agency

C HCAHPS is a survey that has become a standard for measuring and comparing quality of hospitals. It is a survey of patient perceptions.

Which principle is most important for a nurse to follow when using a clinical practice guideline for an assigned patient? A. Knowing the source of the guideline B. Reviewing the evidence used to develop the guideline C. Individualizing how to apply the clinical guideline for a patient D. Explaining to a patient the purpose of the guideline

C Individualizing patient care is still the important principle for implementing care, even when a clinical guideline is used. Explaining any interventions in a guideline to the patient is important but not the most critical factor in implementing care. Reviewing the source of the guideline and applicable evidence do not directly benefit a patient.

Assisting a patient with oral care is an example of: A. Counseling B. Lifesaving measure C. Physical care technique D. Activity of daily living

D

A nurse collects equipment needed to administer an enema to a patient. Previously the nurse reviewed the procedure in the policy manual. The nurse raises the patient's bed and adjusts the room lighting to illuminate the work area. A patient care technician comes into the room to assist. Which aspect of organizing resources and care delivery did the nurse omit? A. Environment B. Personnel C. Equipment D. Patient

D In preparing to administer the enema, the nurse did not prepare for the patient's physical and psychological comfort.