NCLEX Practice, Taylor (8th ed.) Chapter 14 Implementing

8. A nurse develops a detailed plan of care for a 16-year-old female who is a new single mother of a premature infant. The plan includes collaborative care measures and home health care visits. When presented with the plan, the patient states, "We will be fine on our own. I don't need any more care." What would be the nurse's best response?

c. When a patient does not follow the plan of care despite your best efforts, it is time to reassess strategy. The first objective is to identify why the patient is not following the therapy. If the nurse determines, however, that the plan of care is adequate, the nurse must identify and remedy the factors contributing to the patient's noncompliance.

2. A nurse is using the implementation step of the nursing process to provide care for patients in a busy hospital setting. Which nursing actions best represent this step? Select all that apply.

a, d, f. During the implementing step of the nursing process, nursing actions planned in the previous step are carried out. The purpose of implementation is to assist the patient in achieving valued health outcomes: promote health, prevent disease and illness, restore health, and facilitate coping with altered functioning. Assessing a patient for nutritional status or insurance coverage occurs in the assessment step, and formulating nursing diagnoses occurs in the diagnosing step.

1. A school nurse notices that a female adolescent student is losing weight and decides to perform a focused assessment of her nutritional status to determine if she has an eating disorder. How should the nurse proceed?

a. Performing a focused assessment is an independent nurse-initiated intervention, thus the nurse does not need an order from the physician or the nutritionist.

7. A student nurse is on a clinical rotation at a busy hospital unit. The RN in charge tells the student to change a surgical dressing on a patient while she takes care of other patients. The student has not changed dressings before and does not feel confident with the procedure. What would be the student's best response?

a. Student nurses should notify their nursing instructor or nurse mentor if they believe they lack any competencies needed to safely implement the plan of care. It is within the realm of a student nurse to change a dressing if he or she is technically prepared to do so.

9. An RN working on a busy hospital unit delegates patient care to unlicensed assistive personnel (UAPs). Which patient care could the nurse most likely delegate to a UAP safely? Select all that apply.

b, c, e, f. Performing the initial patient assessment and administering medications are the responsibility of the registered nurse. In most cases, patient hygiene, bed-making, ambulating patients, and helping to feed patients can be delegated to a UAP.

6. A nurse is about to perform pin site care for a patient who has a halo traction device installed. What is the first nursing action that should be taken prior to performing this care?

b. Before implementing any nursing action, the nurse should reassess the patient to determine whether the action is still needed. Then the nurse may collect the equipment, explain the procedure, and if necessary administer pain medications.

3. Nurses use the Nursing Interventions Classification Taxonomy structure as a resource when planning nursing care for patients. What information would be found in this structure?

b. The Nursing Interventions Classification 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.

5. A nurse performs nurse-initiated nursing actions when caring for patients in a skilled nursing facility. Which are examples of these types of interventions? Select all that apply.

c, d, f. Nurse-initiated interventions, or independent nursing actions, involve carrying out nurse-prescribed interventions resulting from their assessment of patient needs written on the nursing plan of care, as well as any other actions that nurses initiate without the direction or supervision of another health care professional. Protocols and standard orders empower the nurse to initiate actions that ordinarily require the order or supervision of a physician. Consulting with a psychiatrist is a collaborative intervention.

4. A new RN is being oriented to a nursing unit that is currently understaffed and is told that the UAPs have been trained to obtain the initial nursing assessment. What is the best response of the RN?

c. The nurse should not delegate this nursing admission assessment because only nurses can perform this intervention. The nurse should seek clarification for this policy from the nursing administration.

10. A student nurse is organizing clinical responsibilities for an 84-year-old female patient who is diabetic and is being treated for foot ulcers. The patient tells the student, "I need to have my hair washed before I can do anything else today; I'm ashamed of the way I look." The patient's needs include diagnostic testing, dressing changes, meal planning and counseling, and assistance with hygiene. How would the nurse best prioritize this patient's care?

d. As long as time constraints permit, the most important priorities when scheduling nursing care are priorities identified by the patient as being most important. In this case, washing the patient's hair and assisting with hygiene puts the patient first and sets the tone for an effective nurse-patient partnership.