NURSING PROCESS " IMPLEMENTING"
Which examples of nursing actions involve direct care of the client? Select all that apply. A. A nurse counsels a young family who is interested in natural family planning. B. A nurse massages the back of a client while performing a skin assessment. C. A nurse arranges for a consultation for a client who has no health insurance. D. A nurse helps a client in hospice fill out a living will form. E. A nurse arranges for physical therapy for a client who had a stroke.
A. A nurse counsels a young family who is interested in natural family planning. B. A nurse massages the back of a client while performing a skin assessment. D. A nurse helps a client in hospice fill out a living will form. A direct care intervention is a treatment performed through interaction with the client(s). Direct care interventions include both physiologic and psychosocial nursing actions, and include both the "laying of hands" actions and those that are more supportive and counseling in nature. An indirect care intervention is a treatment performed away from the client but on behalf of a client or group of clients. Indirect care interventions include nursing actions aimed at management of the client care environment and interdisciplinary collaboration.
A nurse works in a long-term care facility where standing orders are in place for influenza vaccines for all residents. What is the nurse's priority, when carrying out the prescriptions? A. Assessing whether the patient previously received the vaccine B. Refusing to give the vaccine without a written prescription C. Determining if the standing orders are inappropriate for their unit D. Calling the nursing supervisor to determine if this is a permitted action
A. Assessing whether the patient previously received the vaccine Standard orders empower the nurse to initiate actions ordinarily requiring the order, prescription or supervision of a health care provider. The nurse first assesses whether the patient has already received the vaccine. The standing order is a valid prescription given to cover common, recurring actions the nurse can use when indicated.
A nurse is caring for a group of patients. Which actions are appropriate to include in the implementation phase of care? Select all that apply. A. Changing the dressings on a burn victim's arm B. Assessing a patient's nutritional intake C. Formulating a nursing diagnosis for a patient with epilepsy D. Turning a patient in bed every 2 hours to prevent pressure injuries E. Checking a patient's insurance coverage at the initial interview F. Determining availability of community resources for a patient with dementia
A. Changing the dressings on a burn victim's arm D. Turning a patient in bed every 2 hours to prevent pressure injuries F. Determining availability of community resources for a patient with dementia During the implementing step of the nursing process, nursing actions that were formulated during the planning process are carried out. The purpose of the implementation phase is to assist the patient in achieving valued health outcomes, for example promote health, prevent disease and illness, restore health, and facilitate coping with altered functioning. Assessing a patient's nutritional status or insurance coverage occurs in the assessment step, and formulating nursing diagnoses occurs in the diagnosing/analyzing step.
A school nurse determines that a student who has lost weight is at risk for an eating disorder and would benefit from a nutritional assessment. What action will the nurse take? A. Perform a focused nutritional assessment B. Seek direction from the student's health care provider C. Suggest the student visit the nurse-run clinic D. Request a consultation with a nutritionist
A. Perform a focused nutritional assessment Performing a focused assessment is an independent nurse-initiated intervention, not requiring a prescription from or intervention by the health care provider, advanced practice nurse, or nutritionist.
The emergency room nurse is performing an initial assessment of a new client who presents with severe dizziness. The client reports a medical history of hypertension, gout, and migraine headaches. Which step should the nurse take first in the comprehensive assessment? A. Perform vital signs and blood glucose level. B. Discuss the need to change positions slowly, especially when moving from sitting to standing. C. Perform a full review of systems. D. Initiate an intravenous line and administer 500mL of normal saline.
A. Perform vital signs and blood glucose level. A client who presents with severe dizziness needs a comprehensive assessment, including vital signs and blood glucose level, prior to any other action. The results of the assessment could help determine which actions to take next. Discussing the need to change positions slowly and home blood pressure monitoring may be appropriate educational activities for this client, but the assessment should be performed first to be sure that the client's symptoms are caused by hypotension. The client may also need intravenous fluids to help correct hypotension, but the client must be assessed first.
After learning about a client's limited financial resources and limited insurance benefits, the home care nurse modifies nursing interventions related to a client's care instructions. The nurse modifies the plan of care based upon which client variable? A. Psychosocial background B. Developmental stage C. Research findings D. Current standards of care
A. Psychosocial background The nurse is demonstrating an awareness of the client's psychosocial background, which includes consideration of the client's socioeconomic status. Research findings and current standards of care are examples of nursing variables. Developmental stage is a client variable that addresses the developmental needs of a client.
A nurse is caring for a patient with a painful, non-healing surgical wound. The patient does not request pain medication because they do not want to be a burden. What actions will the nurse implement to improve pain relief? Select all that apply. A. Reestablishing the pain level the patient finds acceptable as the pain management goal B. Obtaining a dry-erase board to remind the patient of the plan of care C. Assessing the patient's pain and offering analgesia during hourly rounding D. Placing the analgesic underneath other medications and quickly handing it to the patient E. Asking the family members to speak to the patient about pain relief
A. Reestablishing the pain level the patient finds acceptable as the pain management goal B. Obtaining a dry-erase board to remind the patient of the plan of care C. Assessing the patient's pain and offering analgesia during hourly rounding The nurse reassesses the patient's knowledge and acceptance of the plan of care, including the level of pain the patient finds acceptable. Using a dry-erase board and hourly rounding further communicate and reinforce the care plan. The nurse develops a compassionate and trusting relationship with the patient; the nurse and patient mutually determine the plan for pain management, not their family.
The charge nurse tells a nursing student to change a surgical dressing while they take care of other patients. The student has not changed dressings before and does not feel confident performing the procedure. What action should the student take? A. Tell the charge nurse that they lack the technical competencies to change the dressing independently B. Assemble the equipment for the procedure and follow the steps in the procedure manual C. Ask another student nurse to work collaboratively with them to change the dressing D. Tell the clinical instructor they have not had experience with the delegated task
A. Tell the charge nurse that they lack the technical competencies to change the dressing independently Student nurses should notify their nursing instructor or nurse preceptor if they believe they lack any competencies needed to safely implement the care plan. Once educated and technically prepared, the nursing student may perform a dressing change.
A nursing unit has adopted use of a care bundle for insertion of central venous catheters. During the procedure, which action by a nurse requires the charge nurse to intervene? A. They discard the sterile drapes in the insertion kit. B. The primary nurse reminds everyone in the room to wear a mask. C. The team includes every item in the bundle during the procedure. D. The nursing student states using the bundle improves patient outcomes.
A. They discard the sterile drapes in the insertion kit. Care bundles are sets of evidence-based interventions that, when performed together and consistently, improve the process of care and patient outcomes. Discarding sterile drapes from the insertion kit circumvents this process.
After administering the prescribed pain medication, which intervention should the nurse include in the nursing care plan to monitor and evaluate pain? A. Assess nonpharmacologic modalities used to reduce pain. B. Implement the ABC guide of pain management. C. Ambulate the client after administration of pain medication. D. Review client goals for comfort.
B. Implement the ABC guide of pain management. Because administering a pain medication is implementing the plan of care, the next step would be to monitor and evaluate the client's pain level. By using the ABC guide to pain management in reassessing the client's pain, the nurse knows whether the current plan of care is safe and effective for the client, or if changes need to be made to meet the client's needs. Stating the use of pharmacologic and nonpharmacologic pain management modalities and ambulation and reviewing goals for comfort are all interventions to reduce pain, not methods for monitoring pain or evaluating the current plan.
An RN working on a hospital unit frequently delegates patient care to assistive personnel (AP). Which activities are appropriate for the nurse to safely delegate? Select all that apply. A. Performing patient assessments B. Making patient beds C. Giving patients bed baths D. Administering oral medications E. Ambulating patients F. Assisting patients with meals
B. Making patient beds C. Giving patients bed baths E. Ambulating patients F. Assisting patients with meals AP assist the RN to provide care as delegated by and under their supervision. Typical tasks delegated include actions for stable patients (e.g., vital signs hygiene, bed-making, ambulating patients, and helping to feed patients). Performing the initial patient assessment and administering medications are the responsibility of the RN.
Nurses use the Nursing Interventions Classification (NIC) Taxonomy structure as a resource to plan nursing care for patients. What information is found in this structure? A. Case studies illustrating a complete set of activities that a nurse performs to carry out nursing interventions B. Nursing interventions, each with a label, a definition, and a set of activities that a nurse performs to carry it out, with a short list of background readings C. Complete list of nursing diagnoses, outcomes, and related nursing activities for each nursing intervention D. Complete list of reimbursable charges for each nursing intervention
B. Nursing interventions, each with a label, a definition, and a set of activities that a nurse performs to carry it out, with a short list of background readings The Nursing Interventions Classification (NIC) Taxonomy lists nursing interventions, each with a label, a definition, a set of activities that a nurse performs to carry it out, and a short list of background readings. It does not contain case studies, diagnoses, or charges.
What is the priority goal of interventions for a risk diagnosis? A. Reduce or eliminate contributing factors B. Prevent an actual problem C. Collect additional data D. Promote higher level wellness
B. Prevent an actual problem For "risk" nursing diagnoses, the priority goal is to prevent the problem from occurring by implementing interventions that reduce or eliminate risk factors or by collecting additional data. Promoting higher level wellness is a goal for "actual" nursing diagnoses.
A nurse enters the patient's room to perform pin-site care for a patient wearing a halo vest to stabilize the cervical spine. What action will the nurse take first? A. Administer pain medication B. Reassess the patient C. Prepare the equipment D. Explain the procedure to the patient
B. Reassess the patient Before implementing any nursing action, the nurse returns to the first step of the nursing process, reassessing whether the action is still needed. Then the nurse may collect the equipment, explain the procedure, and, if necessary, administer pain medications.
The nurse is caring for a postoperative client who is receiving morphine sulfate for pain management. The nurse obtains the following vital signs: heart rate, 74 beats/min; respiratory rate, 8 breaths/min; blood pressure, 114/68 mm Hg. After reviewing the nursing care plan and health care provider orders, the nurse administers naloxone. Which would allow the nurse to initiate this action? A. Algorithm B. Standing orders C. Protocol D. Order set
B. Standing orders Standing orders allow the nurse to initiate actions that ordinarily require the order of a health care provider, such as administering naloxone. An algorithm is a binary decision tree that guides stepwise assessment and intervention for a high-risk subgroup of clients. A protocol is a written plan that details nursing activities to be executed in specific situations. An order set is a preprinted set of provider orders that expedite the provider order process.
A nurse develops a care plan for an adolescent patient who gave birth to a premature infant. When presented with the collaborative care plan, including home health care visits, the patient states, "We will be fine on our own. I don't need any more care." What is the nurse's best response? A. "You know your personal situation better than I do; I will respect your wishes." B. "If you don't accept these services, your baby's health will suffer." C. "Let's take a look at the plan again and see if we can adjust it to fit your needs." D. "I'm going to assign your case to a social worker who can explain the services better."
C. "Let's take a look at the plan again and see if we can adjust it to fit your needs." When a patient rejects the care plan, the nurse works to identify the underlying barriers. If the nurse determines that the care plan is adequate, the nurse works with the patient to formulate mutually developed goals and interventions.
A nurse performs nurse-initiated nursing actions when caring for patients in a skilled nursing facility. Which reflect these types of actions? Select all that apply. A. Administering an antibiotic to a patient with pneumonia B. Consulting with a psychiatrist for a patient who misuses opiates C. Checking the skin of bedridden patients for skin breakdown D. Ordering a kosher meal for an orthodox Jewish patient E. Recording a patient's intake and output F. Preparing a patient for surgery according to facility protocol
C. Checking the skin of bedridden patients for skin breakdown D. Ordering a kosher meal for an orthodox Jewish patient F. Preparing a patient for surgery according to facility protocol Nurse-initiated interventions, or independent nursing actions, include nurse-prescribed interventions resulting from their assessment of patient's actual or potential health problems. Protocols and standard orders empower the nurse to initiate actions that ordinarily require the order or supervision of a health care provider. Consulting with a psychiatrist is a collaborative intervention.
The nurse is proceeding through the nursing process in the care of a new client. During the implementation phase, the nurse will most likely accomplish what task? A. Establish trust and rapport with the client B. Identify a need for collaborative consults C. Help the client achieve optimal levels of health D. Implement the critical pathway for the client
C. Help the client achieve optimal levels of health The purpose of the nursing implementation phase is to help the client achieve an optimal level of health. Implementing the critical pathway for the client is too narrow to represent the purpose of the implementation phase, although this may be the purpose of specific interventions that would be implemented during this phase. Identifying the need for collaborative consults is an action the nurse would perform in the planning phase of the nursing process. Establishing trust happens earlier in the nursing process.
Which statement best explains why continuing data collection is important? A. It is difficult to collect complete data in the initial assessment. B. It is the most efficient use of the nurse's time. C. It enables the nurse to revise the care plan appropriately. D. It meets current standards of care.
C. It enables the nurse to revise the care plan appropriately. Continuous data collection ensures that the nurse has the most current client data to evaluate, which allows for updating the care plan as needed. A complete assessment is performed on admission, but the client's condition is always changing. The purpose of continued data collection is to provide good client care; it does not relate directly to efficiency of nursing care. While continuous data collection meets standards of care, it is not the primary reason for ongoing assessments.
A nursing student is prioritizing interventions for a patient with diabetes who needs diagnostic testing, dressing changes, meal planning and counseling, and assistance with hygiene. The patient states, "I must have my hair washed before I can do anything else; I'm ashamed of the way I look." How will the student best prioritize this patient's care? A. Explain to the patient that there is not enough time to wash their hair today because of the busy schedule B. Schedule the testing and meal planning first and complete hygiene as time permits C. Perform the dressing changes first, schedule the testing and counseling, and complete hygiene last D. Wash the patient's hair and perform hygiene, schedule testing and counseling, then change the dressing
D. Wash the patient's hair and perform hygiene, schedule testing and counseling, then change the dressing When time constraints and safety permit, priorities identified by the patient as most important are completed first. Washing the patient's hair and assisting with hygiene put the patient first, setting the tone for an effective nurse-patient partnership.
