26 Quiz 8 - The Nursing Process - Implementing

One of the advantages of using Nursing Intervention Classifications in nursing practice is to ensure appropriate reimbursement for nursing services. a. True b. False

A. True One of the advantages of using Nursing Intervention Classifications in nursing practice is to ensure appropriate reimbursement for nursing services.

When a patient fails to cooperate with the plan of care despite the nurse's best efforts, it is time to reassign the patient to another caretaker. a. True b. False

B. False When a patient fails to cooperate with the plan of care despite the nurse's best efforts, it is time to reassess the strategy.

Which of the following nursing actions is considered an independent (nurse-initiated) action? a. Executing physician orders for a catheter b. Meeting with other healthcare professionals to discuss a patient c. Helping to allay a patient's fears about surgery d. Administering medication to a patient

c. Helping to allay a patient's fears about surgery

Which one of the following nursing interventions is an indirect care intervention? a. A nurse explains available birth control measures to a young couple. b. A nurse meets with the collaborative care team to plan nursing measures for a patient. c. A nurse prays with a patient prior to surgery. d. A nurse administers pain medication to a patient with end-stage renal cancer.

B. A nurse meets with the collaborative care team to plan nursing measures for a patient. Rationale: An indirect care intervention is treatment performed away from the patient but on behalf of a patient or group of patients, such as the example in answer B: consulting with the collaborative care team. The remaining answer options are direct care interventions or treatment performed through interaction with the patient.

A nurse who follows the protocol for taking vital signs following surgery is performing a physician-initiated intervention. a. True b. False

B. False A nurse who follows the protocol for taking vital signs following surgery is performing a nurse-initiated intervention.

Which one of the following is an example of a nurse variable influencing patient outcomes? a. A patient in a nursing home refuses to take his medications. b. A low-income family is unable to afford formula for their newborn infant. c. An alcoholic patient is unwilling to participate in AA meetings. d. A rape victim does not receive counseling at the ER because a counselor is not available.

D. A rape victim does not receive counseling at the ER because a counselor is not available. Rationale: Nurse variables that influence the plan of care include resources (Answer D), current standards of care, research findings, & ethical & legal guides to practice. The remaining answer options are patient variables, which include the patient's changing ability & willingness to participate in the plan of care & personal responses to the nursing interventions implemented.

Which of the following activities would be carried out during the implementation step of the nursing process? (Select All That Apply) a. Collecting additional patient data b. Modifying the patient plan of care c. Performing an initial assessment of the patient d. Developing patient outcomes & goals e. Measuring how well the patient has achieved patient goals f. Collecting a database to enable an effective plan of care

a, b

Which of the following are goals of the research behind the Nursing Outcomes Classifications (NOCs)? (Select All That Apply) a. To identify, label, & validate nursing-sensitive patient outcomes & indicators b. To teach decision making c. To ensure appropriate reimbursement for nursing services d. To communicate nursing to non-nurses e. To evaluate the validity & usefulness of the classification in clinical field testing f. To define & test measurement procedures for the outcomes & indicators

a, e, f

Which of the following are advantages of having standard nursing interventions classifications (NICs)? (Select All That Apply) a. Limiting the amount of reimbursement allowed for nursing services. b. Teaching decision making c. Allocating nursing resources d. Allowing the use of multiple systems of nomenclature e. Developing information systems f. Communicating nursing to non-nurses

b, c, e, f

Your patient, who presented with high blood pressure, is put on a low-salt diet & instructed to quit smoking. You find him in the cafeteria eating a cheeseburger & French fries. He also tells you there is no way he can quit smoking. What is your first objective when implementing care for this patient? a. Explain to the patient the effects of a high-salt diet & smoking on blood pressure. b. Identify why the patient is not following the therapy. c. Collaborate with other healthcare professionals about the patient's treatment. d. Change the nursing care plan.

b. Identify why the patient is not following the therapy.

Which of the following phrases best describes the unique focus of nursing implementation? a. The selected aspects of the patient's treatment regimen b. The response of the patient to the plan of care in general c. The response of the patient to the illness d. The patient's ability to work with support people to promote wellness

b. The response of the patient to the plan of care in general

As the nurse bathes a patient, she notes his skin color & integrity, his ability to respond to simple directions, & his muscle tone. Which of the following statements best explains why such continuing data collection is so 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

Which of the following are listed in the ANNs Nursing: Scope & Standards of Practice for Standard 5: Implementation? (Select All That Apply) a. The nurse demonstrates quality by documenting the application of the nursing process in a responsible, accountable, & ethical manner. b. The nurse incorporates new knowledge to initiate changes in nursing practice if the desired outcomes are not achieved. c. The nurse develops expected outcomes that provide direction for the continuity of care. d. The nurse documents implementation & any modifications, including changes or omissions, of the identified plan. e. The nurse utilizes community resources & systems to implement the plan. f. The nurse utilizes evidence-based interventions & treatments specific to the diagnosis or problem.

d, e, f

Which of the following terms denotes a nurse's authority to initiate actions that normally require the order or supervision of a physician? a. Protocols b. Nursing interventions c. Collaborative orders d. Standing orders

d. Standing orders