Taylor- Fundamentals of Nursing Chp 15

C

5. What role of the nurse is crucial to the prevention of fragmentation of care? A) advocate B) teacher C) counselor D) coordinator

A

6. What phrase best describes nurse-initiated interventions? A) nurse-prescribed interventions B) physician-prescribed interventions C) healthcare team interventions D) interventions based on medical orders

A

1. What is the unique focus of nursing implementation? A) patient response to health and illness B) patient response to nursing diagnosis C) patient compliance with treatment regimen D) patient interview and physical assessment

D

10. What must occur before physician-initiated interventions can be carried out? A) They must be written on the nursing plan of care. B) The nurse relinquishes all responsibility for them. C) Any healthcare provider may order them. D) The physician gives a verbal or written order.

D

11. A patient who was previously awake and alert suddenly becomes unconscious. The nursing plan of care includes an order to increase oral intake. Why would the nurse review the plan of care? A) to implement evidence-based practice B) to ensure the order follows hospital policy C) to be sure interventions are individualized D) to be sure the intervention is safe

B

12. A nurse is preparing to insert an intravenous line and begin administering intravenous fluids. The patient has visitors in the room. What should the nurse do? A) Ask the visitors to leave the room. B) Ask the patient if visitors should remain in the room. C) Tell the patient to ask the visitors to leave the room. D) Wait until the visitors leave to begin the procedure.

C

13. A nurse is catheterizing a patient. What action illustrates respect for the patient's privacy? A) explaining the procedure to the family B) leaving the patient's pajamas on C) closing the door to the room D) asking another nurse if he wants to watch

D

14. A student is ambulating a patient for the first time after surgery. What would the student do to anticipate and plan for an unexpected outcome? A) Take the patient's vital signs after ambulation. B) Ask the patient's wife to assist with ambulation. C) Delay ambulation until the following shift. D) Ask another student to help with ambulation.

A

15. Each time a nurse administers an insulin injection to a patient with diabetes, she tells the patient what she is doing and demonstrates each step of preparing and giving the injection. What is the nurse promoting? A) self-care B) dependence C) coping with disability D) nurse-patient relationship

B,D,F

16. Which of the following statements accurately describe a recommended guideline for implementation? Select all that apply. A) When implementing nursing care, remember to act independently, regardless of the wishes of the patient/family. B) Before implementing any nursing action, reassess the patient to determine whether the action is still needed. C) Assume that the nursing intervention selected is the best of all possible alternatives. D) Consult colleagues and the nursing and related literature to see if other approaches might be more successful. E) Reduce your repertoire of skilled nursing interventions to ensure a greater likelihood of success. F) Check to make sure that the nursing interventions selected are consistent with standards of care.

C

17. The staff in a long-term care facility often plays loud rock music on the radio and designs children's games as exercise. What is the staff doing in this situation? A) considering the hearing level of older adults B) failing to consider visual deficits that occur with aging C) ignoring the developmental needs of older adults D) meeting needs for sensory input and exercise

D

18. A nurse administers a medication for pain but forgets to document it in the patient's medical record. Legally, what does this mean? A) Nothing, the nurse's honesty will not be questioned. B) The nurse can add the documentation after the patient goes home. C) The physician will verify that the nurse carried out the order. D) In the eyes of the law, if it is not documented, it was not done.

C

19. A nurse delegates a specific intervention to a UAP. What implications does this have for the nurse? A) The UAP is responsible and accountable for his or her own actions. B) Nurses do not have authority to delegate interventions. C) The nurse transfers responsibility but is accountable for the outcome. D) The UAP can function in an independent role for all interventions.

A

2. What is one advantage of having a standard classification of nursing interventions? A) to standardize nomenclature (names or terms) B) to legitimize the use of the nursing process C) to classify indicators of patient outcomes D) to facilitate documentation of expected goals

A

20. According to the American Nurses Association, who determines the scope of nursing practice? A) nurses B) lawyers C) physicians D) consumers

D

21. What characteristic of a competent nurse practitioner enables nurses to be role models for patients? A) sense of humor B) writing ability C) organizational skills D) good personal health

C

22. What core value of nursing care is missing when a nursing intervention is delegated to a UAP? A) communication B) patient teaching C) nurse/patient dynamic D) competent care

B

3. The researchers developing classifications for interventions are also committed to developing a classification of which of the following? A) diagnoses B) outcomes C) goals D) data clusters

C

4. What activity is carried out during the implementing step of the nursing process? A) Assessments are made to identify human responses to health problems. B) Mutual goals are established and desired patient outcomes are determined. C) Planned nursing actions (interventions) are carried out. D) Desired outcomes are evaluated and, if necessary, the plan is modified.

A,B,D,E

7. Which of the following examples of nursing actions involve direct care of the patient? 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 patient while performing a skin assessment. C) A nurse arranges for a consultation for a patient who has no health insurance. D) A nurse helps a patient in hospice fill out a living will form. E) A nurse arranges for physical therapy for a patient who had a stroke. F) A nurse comforts a distraught patient whose baby was stillborn.

B

8. A nurse documents the following diagnosis for a hospitalized patient: Risk for Imbalanced Nutrition: More Than Body Requirements. What is the major goal of interventions for a risk diagnosis? A) reduce or eliminate contributing factors B) prevent the problem C) collect additional data D) promote higher-level wellness

C

9. A nurse is changing a sterile pressure ulcer dressing based on an established protocol. What does this mean? A) The nurse is using critical thinking to implement the dressing change. B) The patient has specified how the dressing should be changed. C) Written plans are developed that specify nursing activities for this skill. D) The physician verbally requested specific steps of the dressing change.