Chapter 6. Nursing Process: Planning Interventions
Which definition best describes a critical pathway? 1) Standardized plan of care for frequently occurring conditions 2) Systematically developed statement to assist practitioners and patients in making decisions 3) Systematic review of clinical evidence for an intervention 4) Set of interrelated concepts that describes or explains something
ANS: 1 Critical pathways are standardized plans of care for commonly occurring health conditions (e.g., myocardial infarction) for which similar outcomes and interventions are appropriate for the majority of patients with the condition. Clinical practice guidelines are systematically developed statements to assist practitioners and patients in making decisions about appropriate healthcare for a particular disease or procedure. Evidence reports are systematic reviews on clinical topics for the purpose of providing evidence for guidelines, quality improvement, quality measures, and insurance coverage decisions. A theory is a set of interrelated concepts that describe or explain something. PTS:1DIF:EasyREF: p. 104 KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall
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? 1) Determine airway adequacy hourly and as needed. 2) Administer oxygen as needed. 3) Monitor arterial blood gas values. 4) Place the client in a high Fowler's position.
ANS: 1 For any acute respiratory problem, prior to implementing interventions, the nurse would assess breathing status of the patient by checking the respiratory rate and depth. When devising a plan of care for the client, nursing interventions should be listed according to priority. Airway always takes precedence, as ventilation, oxygenation, and positioning will be ineffective without a patent airway. PTS: 1 DIF: Difficult REF: p. 107 KEY: Nursing process: Planning | Client need: Physiological integrity | Cognitive level: Analysis
Which standardized intervention vocabulary was designed specifically for community health nurses? 1) Omaha System 2) Clinical Care Classification 3) Nursing Interventions Classification 4) International Classification for Nursing Practice
ANS: 1 The Omaha System was designed specifically for community health nurses to use in caring for individuals, families, community groups, or entire communities. The Clinical Care Classification was developed for home healthcare. The Nursing Interventions Classification system is applicable in all settings, including home health and community nursing. The International Classification for Nursing Practice system was designed to describe nursing practice of individuals, families, and communities worldwide. PTS:1DIF:EasyREF: p. 110 KEY: Nursing process: Planning | Client need: SASE | Cognitive level: Recall
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 the program generates, he sees that none of them fit this patient's individual needs. What should the nurse do? 1) Reject them all and type in appropriate interventions. 2) Select the interventions from the program that are most suitable. 3) Ask another nurse to assess the patient and give her recommendation. 4) Restart the computer; it is probably a program malfunction.
ANS: 1 The nurse can reject all the suggested interventions if they do not address patient needs. Nearly all computer programs have a screen that allows you to type in interventions and nursing orders. It is the nurse's responsibility to choose interventions: He cannot abdicate this responsibility and let the computer "choose." As a professional, this nurse has already validated the data, nursing diagnosis, and goals, so he can feel reasonably certain that there is nothing wrong with the plan to that point. Although consultation with other nurses can be wise and prudent at times, the nurse caring for the patient would likely have the most familiarity with the healthcare needs and is in a better position to make sound judgments than another nurse who does not know the patient. Therefore, it might not be productive or efficient to consult another nurse or restart the computer. PTS:1DIF:ModerateREF:p. 108-109 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis
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? 1) 7/12/13 Encourage use of the incentive spirometer every hour while the client is awake—D. Goodman, RN 2) By 7/12/13, uses incentive spirometer 10 times every hour while awake to 1000 mL 3) Incentive spirometer hourly while awake 4) Offer incentive spirometer to the client—J. Smith, RN
ANS: 1 The option beginning with a date and ending with the RN's signature contains necessary information. It contains the date the order was written along with specific instruction for the nurse that is written in terms of nursing behavior. "Uses incentive spirometer 10 times . . ." is an example of an expected outcome. "Incentive spirometer hourly . . ." is an example of a medical order. Plus, the date and nurse's signature are missing. "Offer incentive spirometer . . ." does not provide the nurse with enough detailed instruction. Therefore, it is a poorly written nursing order. PTS:1DIF:ModerateREF:pp. 111-112 KEY: Nursing process: Planning | Client need: Physiological integrity | Cognitive level: Application
Which statement(s) about nursing interventions is/are true? Select all that apply. 1) The responsibility of writing nursing orders cannot be delegated to the LPN/LVN. 2) The best nursing interventions are based on tradition. 3) Nursing interventions should be individualized and culturally sensitive. 4) Standardized nursing interventions improve care for a specific client.
ANS: 1, 3 Some nursing interventions and activities can be delegated to the LPN/LVN or nursing assistive personnel (NAP); however, writing nursing orders is the responsibility of the registered nurse. Nursing interventions should always be individualized and culturally sensitive. Whenever possible, nursing interventions should be based on scientific evidence, not tradition. Standardized interventions are not customized to improve care for a specific client. PTS:1DIF:ModerateREF: pp. 103-104 KEY: Nursing process: Interventions | Client need: SASE | Cognitive level: Application
An 80-year-old resident in a long-term-care facility comes to the emergency department with dehydration. The nurse writes a diagnosis of Deficient Fluid Volume related to excessive fluid loss. An individualized nursing goal identified for this client is "The client will maintain urine output of at least 30 mL/hour." Which nursing interventions would directly help achieve or evaluate the stated goal? Choose all that are correct. 1) Measure and record urine output every hour; report an output of less than 30 mL/hour. 2) Monitor skin turgor and moistness of mucous membranes every shift. 3) Administer IV fluids as prescribed. 4) Keep oral fluids within the patient's reach, and encourage the patient to drink.
ANS: 1, 3, 4 Measuring and recording urine output allow for direct evaluation of the goal "urine output 30 mL/hour." Administering IV fluids adds fluid to correct dehydration, improve blood flow through the kidneys, and increase urine production. Intake of oral fluids has the same effect. Monitoring skin turgor and mucous membranes are ways to assess for dehydration, but it does not directly apply to the goal of maintaining urine output. It is an intervention aimed at the etiology of this nursing diagnosis, rather than the problem. PTS:1DIF:ModerateREF:p. 106-107; high-level question; answer not given verbatim KEY: Nursing process: Interventions | Client need: Physiological integrity | Cognitive level: Analysis
Which nursing intervention is considered an independent intervention? 1) Administering 1 L of dextrose 5% in normal saline solution at 100 mL/hour 2) Encouraging the postoperative client to perform coughing and deep breathing exercises 3) Explaining his diet to the client; then communicating the teaching with the dietitian 4) Administering morphine sulfate 2 mg IV to the client with postoperative pain
ANS: 2 Encouraging the postoperative client to perform coughing and deep breathing exercises is an independent nursing intervention. An independent intervention is one that nurses are licensed to prescribe, perform, or delegate based on their skills and knowledge. Administering IV fluid or morphine sulfate are dependent interventions; they require an order from a physician or advanced practice nurse but are carried out by the nurse. Explaining to the client how sodium intake affects his heart failure and then communicating the teaching with the dietitian is an interdependent intervention, one that is carried out in collaboration with other healthcare team members. PTS:1DIF:ModerateREF: p. 103 KEY: Nursing process: Interventions | Client need: SASE | Cognitive level: Application
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? 1) Identify several interventions likely to achieve the desired outcomes. 2) Review the problem and etiology of the nursing diagnosis. 3) Choose the best interventions for the patient. 4) Review the goals she has written.
ANS: 2 The process of choosing interventions is review the nursing diagnosis, review the desired outcomes, identify several interventions or actions, choose the best interventions for the patient, and then individualize standardized interventions to meet the patient's unique needs. PTS:1DIF:ModerateREF: p. 106-107 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis
Which of the following nursing interventions is an indirect-care intervention? 1) Emotional support 2) Teaching 3) Consulting 4) Physical care
ANS: 3 An indirect-care intervention is an activity performed away from the client on behalf of the client. Indirect-care interventions include consulting with other healthcare team members, making referrals, advocacy, and managing the environment. Direct-care interventions include emotional support, patient teaching, and physical care. PTS:1DIF:EasyREF:pp. 103 KEY: Nursing process: Implementation | Client need: SASE | Cognitive level: Recall
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? 1) Consulting the diabetic nurse educator for help with a teaching plan 2) Making arrangements for the client to join a diabetic support group 3) Demonstrating blood glucose monitoring and insulin administration to the client 4) Consulting with the dietician about the client's dietary concerns
ANS: 3 Demonstrating blood glucose monitoring and insulin administration is an appropriate direct-care intervention for this client. Direct-care interventions are performed through intervention with the client and include interventions such as physical care, emotional support, and client teaching. Indirect-care activities include consulting the diabetic nurse educator, making arrangements for the client to join a diabetic support group, and consulting with the dietitian about the client's dietary concerns. Indirect-care activities are performed away from but on behalf of the client. PTS:1DIF:ModerateREF:p. 103 KEY: Nursing process: Interventions | Client need: Physiological integrity | Cognitive level: Application
Who is the primary decision maker when caring for healthy adult clients? 1) Physician 2) Family 3) Client 4) Nurse
ANS: 3 The client is the primary decision maker in the care of healthy clients. The nurse functions as a teacher and health counselor. The physician plays a role in health promotion and screening. The family may give input, but the client is the decision maker. PTS:1DIF:EasyREF: p. 110 KEY: Nursing process: Planning | Client need: Health promotion | Cognitive level: Comprehension
The nurse is performing preoperative teaching for a client who is scheduled for surgery in the morning. The client does not currently have any respiratory problems. The nurse's teaching plan includes coughing and deep breathing exercises. Which type of nursing intervention is the nurse performing? 1) Health promotion 2) Treatment 3) Prevention 4) Assessment
ANS: 3 The nurse is teaching the client coughing and deep breathing exercises, which help prevent postoperative pneumonia. Therefore, the nurse is utilizing a prevention intervention. Prevention interventions are used to help prevent complications, such as postoperative pneumonia. Health-promotion interventions promote a client's efforts to achieve a higher level of wellness. Treatment interventions treat disorders, relieve symptoms, and carry out medical orders. Assessment interventions detect changes in the client's condition and detect potential problems. PTS:1DIF:ModerateREF: p. 106 KEY: Nursing process: Interventions | Client need: Physiological integrity | Cognitive level: Application
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? 1) Collaborative 2) Interdependent 3) Dependent 4) Independent
ANS: 4 Writing an order to reposition the client in a comfortable position is an example of an independent nursing intervention, one that does not require a physician's order. The nurse is licensed to prescribe, perform, or delegate the intervention based on her knowledge and skills. A collaborative or interdependent intervention is one that is carried out in collaboration with other health team members, such as providing the client with a sodium-restricted diet. A dependent intervention is prescribed by a physician or advanced practice nurse; for example, administer oxygen at 2 L/min via nasal cannula. PTS:1DIF:ModerateREF: p. 103 KEY: Nursing process: Interventions | Client need: Physiological integrity | Cognitive level: Application