ch 6 fundies nursing process: planning interventions

Nurses use a five-step process in selecting the best nursing interventions for their patients. Using the five-step process in selecting the best nursing interventions, arrange the list on the left in the correct order of completion on the right. (Enter the number of each step in the proper sequence, do not use commas.) 1). Review the desired outcomes/goals. 2). Identify several actions or interventions. 3). Individualize standardized interventions. 4). Review the nursing diagnosis. 5) Choose the best interventions for the patient.

4 1 2 5 3

A 55-year-old patient returned to the medical-surgical unit after undergoing a right hemicolectomy (abdominal surgery) for colon cancer. Which of the following is an appropriate, correctly written nursing order for this patient?

7/12/15 Encourage use of the incentive spirometer every hour while the client is awake—D. Goodman, RN

The nurse is selecting nursing interventions for her patient with diabetes. The nurse will select interventions using which resources available to her? Select all that apply.

A standardized list of interventions and Interventions generated based on her knowledge base and past experiences

Which of the following is the best example of a well-written nursing order?

Administer pain medication 30 minutes prior to physical therapy exercises.

The nurse has completed the plan of care for her patient with a medical diagnosis of Gall Bladder Disease. In selecting nursing interventions that will best serve to help the patient achieve the desired goals, the nurse will consider which of the following? Select all that apply

Age of the patient, Patient abilities and preferences, Education levels of the nursing staff, and Medical orders

Which of the following best describes evidence-based practice?

An approach that uses the best scientific data to guide nursing practice

Which of the following nursing interventions is an indirect-care intervention?

Consulting

A client newly diagnosed with diabetes is admitted to the hospital because her diabetes is out of control. Which of the following is an appropriate direct-care intervention for this client during her stay?

Demonstrating blood glucose monitoring and insulin administration to the client

A client is admitted to the hospital with an acute respiratory problem resulting from lung disease. The nurse makes a diagnosis of Ineffective Breathing Pattern related to inability to maintain adequate rate and depth of respirations. Which nursing intervention should be listed first on the care plan?

Determine airway adequacy hourly and as needed.

Which of the following best describe the primary goal(s) of evidence-based practice? Select all that apply.

Identify the most effective treatments for disease processes, conditions, or problems and Identify the most cost-effective treatments for disease processes, conditions, or problems

A nurse makes a nursing diagnosis of Acute Pain related to the postoperative abdominal incision. She writes a nursing order to reposition the client in a comfortable position using pillows to splint or support the painful areas. What type of nursing intervention did the nurse write?

Independent

Which of the following is the best example of a well-written nursing order?

Insert Foley catheter if patient has not voided within 8 hours

The nurse is completing her plan of care for a patient with congestive heart failure. In performing a direct-care nursing intervention the nurse will:

Instruct the patient about low sodium and low fat diets

The nurse is performing preoperative teaching for a client who is scheduled for surgery in the morning. The client does not at present have any respiratory problems. The nurse's teaching plan includes coughing and deep-breathing exercises. Which type of nursing intervention is the nurse performing?

Prevention

The nurse is using electronic care planning. He enters the patient's nursing diagnosis into the computer and chooses desired outcomes. He has validated his data, diagnosis, and goals. When he considers the list of interventions that the program generates, he sees that none of them fits this patient's individual needs. What should the nurse do?

Reject them all and type in appropriate interventions.

A client is admitted to the hospital with an acute episode of chronic obstructive pulmonary (lung) disease. The nurse makes a diagnosis of Ineffective Breathing Pattern related to inability to maintain adequate rate and depth of respirations and has recorded the diagnosis and appropriate goals on the care plan. When selecting nursing interventions, what should the nurse do first?

Review the problem and etiology of the nursing diagnosis

Which definition best describes a critical pathway?

Standardized plan of care for frequently occurring conditions

Which statement(s) about nursing interventions is/are true? Select all that apply.

The responsibility of writing nursing orders cannot be delegated to the LPN/LVN and Nursing interventions should be individualized and culturally sensitive.

Who is the primary decision maker when caring for healthy adult clients?

client

The nurse is caring for a 55-year-old male smoker on the medical-surgical unit. The patient states, "I'd really like some help in quitting smoking." As part of her intervention plan she includes a smoking cessation class. What type of intervention is the nurse performing?

wellness