Funds Ch19 Sherpath

The nurse is caring for a post-operative patient. Which intervention is considered to be prevention-oriented? Oxygen administration Dressing change Post-operative ambulation Monitoring intake and output

Post-operative ambulation

What are the highest-priority interventions? Problem-oriented Independent nursing Direct-care Prevention-based

Problem-oriented

Why should the nurse reference Nursing Interventions Classification (NIC) when documenting interventions? It is useful for clinical documentation. It ensures compliance with HIPAA guidelines. It provides information for billing and reimbursement. It helps the nurse determine goal attainment.

It is useful for clinical documentation.

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

Answer: Indirect-care Rationale: Indirect-care Indirect-care interventions benefit the patient, but do not involve face-to-face contact with the patient. Independent nursing Independent nursing interventions are initiated and conducted by the nurse. Direct-care Direct-care interventions involve direct personal contact with the patient. Prevention-based Prevention-based interventions are implemented to prevent problems.

The nurse is caring for a post-operative patient following hip repair. Which intervention is considered to be collaborative? Ambulation with physical therapy Vital sign monitoring Repositioning in bed Administration of pain medication

Ambulation with physical therapy

Which statement about indirect-care interventions is true? Delegation is an indirect-care intervention. Indirect-care interventions are conducted through personal conduct with the patient. Indirect-care interventions include reassessment. Indirect-care interventions are not as important as direct care interventions.

Answer: Delegation is an indirect-care intervention. Rationale: Delegation is an indirect-care intervention. Delegation is an indirect-care intervention based on assessment findings and established care priorities. Indirect-care interventions are conducted through personal conduct with the patient. Direct-care interventions are conducted through personal contact with the patient. Indirect-care interventions include reassessment. Reassessment is a direct-care intervention. Indirect-care interventions are not as important as direct care interventions. Indirect-care and direct-care interventions are equally important.

Which statement about nursing documentation is true? Only direct-care interventions need to be documented. Interventions should only be documented in the care-plan. Missing documentation does not harm patients. Documentation conveys interventions and outcomes to other care providers.

Answer: Documentation conveys interventions and outcomes to other care providers. Rationale: Only direct-care interventions need to be documented. All interventions that are performed by nurses or other health care personnel need to be documented. Interventions should only be documented in the care-plan. Documentation of interventions is most commonly charted in the patient's EHR, care plan, or standardized flow sheets according to agency policy. 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. Documentation conveys interventions and outcomes to other care providers. Nurses must document interventions to accurately convey patient activities, nursing interventions, and patient outcomes to other care providers.

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) Nursing Interventions Classification (NIC) North American Nursing Diagnosis Association International (NANDA-I) Joint Commission and Centers for Medicare and Medicaid

Answer: Health Insurance Portability and Accountability Act (HIPAA) Rationale: Health Insurance Portability and Accountability Act (HIPAA) Within HIPAA guidelines, patient documentation of interventions is provided to insurance companies and others for billing and reimbursement. Nursing Interventions Classification (NIC) NIC is a reference tool for nursing interventions. North American Nursing Diagnosis Association International (NANDA-I) NANDA-I is an organization for nursing taxonomy. Joint Commission and Centers for Medicare and Medicaid Joint Commission is a regulatory agency that provides standards for hospitals to follow; however, it is not HIPAA.

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

Answer: Implementation Rationale: Diagnosis The diagnosis step occurs when the nurse identifies a diagnostic label to describe the patient's condition. Planning When the nurse identifies the interventions to be performed in order to meet the patient goals, the nurse is in the planning phase of the nursing process. Implementation Implementation consists of performing patient care interventions and documenting interventions in the patient's chart. Evaluation Evaluation occurs when the nurse determines level of goal attainment for 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) Nursing Outcomes Classification (NOC) NANDA-I approved list of nursing diagnostic labels Joint Commission Standards

Answer: Nursing Interventions Classification (NIC) Rationale: Nursing Interventions Classification (NIC) When documenting interventions, nurses often reference Nursing Interventions Classification (NIC), which is a comprehensive, research-based, standardized collection of interventions and activities that align with NANDA-I diagnoses and associated Nursing Outcomes Classification (NOC). Nursing Outcomes Classification (NOC) NOC is an outcomes classification system used to determine goal attainment. NANDA-I approved list of nursing diagnostic labels When the nurse is assigning the nursing diagnosis, the nurse consults the NANDA-I approved list of nursing diagnostic labels. Joint Commission Standards Joint Commission standards guide when care-plans are completed and re-evaluated; however, they are not a reference for nursing interventions.

What was Nursing Interventions Classification (NIC) developed to do? Provide a standardized language to document nursing interventions. Encourage nurses to use taxonomy. Evaluate nursing care driven by nursing diagnoses. Identify health problems or life processes so that appropriate nursing care can be provided.

Answer: Provide a standardized language to document nursing interventions. Rationale: Provide a standardized language to document nursing interventions. Nursing Interventions Classification (NIC) was developed by a research team at the University of Iowa to provide a standardized language to describe, define, and document nursing interventions. Encourage nurses to use taxonomy. The NANDA-I list of nursing diagnoses was developed to encourage nurses to use taxonomy. Evaluate nursing care driven by nursing diagnoses. There are many ways to evaluate nursing care driven by nursing diagnosis; however, NIC was not developed for that. Identify health problems or life processes so that appropriate nursing care can be provided. Nursing care plans are developed to identify health problems or life processes so that appropriate nursing care can be provided.

Nurses coordinate many types of interventions when initiating a care plan. How are nursing interventions categorized? Select all that apply. By purpose By priority By timeframe By who initiates or conducts them By type of patient contact

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

Which are the indirect-care interventions? Select all that apply. Collaboration Referrals Delegation Reassessment Patient teaching

Collaboration Referrals Delegation

Which is an example of an indirect-care intervention? Activities of daily living Informal counseling Patient assessment Communication with providers

Communication with providers

The nurse performs patient care interventions according to the individualized care plan. What is the next step in the process? Resolve the interventions. Determine the goals. Document the interventions. Plan the patient's care.

Document the interventions.

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 Reporting lab values Educating on signs of bleeding Educating on dietary modifications

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 Determine the goals Evaluate the patient's response to the interventions Plan the patient's care NOT SURE

Implement the interventions

Match each method of intervention to the appropriate type of intervention. Implemented to manage and treat existing problems Implemented to prevent problems Involves direct personal contact with the patient Does not involve face-to-face contact with the patient Direct-care Indirect-care Prevention-oriented Problem-based

Implemented to manage and treat existing problems Problem-based Implemented to prevent problems Prevention-oriented Involves direct personal contact with the patient Direct-care Does not involve face-to-face contact with the patient Indirect-care

Nurses conduct change-of-shift reports to communicate assessment findings and outstanding nursing interventions. What type of intervention is this? Direct-care Indirect-care Problem-oriented Prevention-oriented

Indirect-care

Which are the direct-care interventions? Select all that apply. Informal counseling ADLs Reassessment Advocacy Research

Informal counseling ADLs Reassessment

Match each method of intervention to the appropriate type of intervention. Initiated and conducted by the nurse Initiated by a provider in the form of an order, and conducted by the nurse Initiated by the nurse and conducted by other health care team members Collaborative nursing Independent nursing Dependent nursing

Initiated and conducted by the nurse Independent nursing Initiated by a provider in the form of an order, and conducted by the nurse Dependent nursing Initiated by the nurse and conducted by other health care team members Collaborative nursing

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

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 Collaborative

Which is an example of a collaborative nursing intervention? Monitoring a patient's temperature and skin color for fever Administering antibiotics for infection as ordered by the provider Nursing assistant providing range-of-motion on the patient Turning a patient every two hours to prevent skin breakdown

Nursing assistant providing range-of-motion on the patient

The nurse is caring for a postoperative patient in the medical-surgical unit. Which interventions are considered to be independent nursing interventions? Select all that apply. Administration of IV fluids Use of incentive spirometer Administration of medications Hand hygiene Ambulating the patient

Use of incentive spirometer Hand hygiene Ambulating the patient