Chapter 19: Implementing Nursing Care

Question 1

1.	In which step of the nursing process does the nurse provide nursing care interventions to patients?
a.
Assessment
b.
Planning
c.
Implementation
d.
Evaluation

Answer 1

ANS: C
In the five-step nursing process, the implementation phase involves providing direct and indirect nursing care interventions to patients. The nurse gathers data during the assessment phase and mutually sets goals and prioritizes care during the planning phase. During the evaluation phase, the nurse determines the effectiveness of interventions.

Question 2

2. The nurse defines a clinical guideline or protocol as a
   a.
   Guideline to follow that replaces the nursing care plan.
   b.
   Document that assists the clinician in making decisions and choosing interventions for specific health care problems or conditions.
   c.
   Hospital policy designating each nurse’s duty according to standards of care and a code of ethics.
   d.
   Prescriptive order form that individualizes the plan of care.

Answer 2

ANS: B
A clinical guideline or protocol is a document that assists the clinician in making decisions and choosing interventions for specific health care problems or conditions. The protocol does not replace the nursing care plan. Evidence-based guidelines from protocols can be incorporated into an individualized plan of care. A clinical guideline is not the same as a hospital policy. Standing orders contain orders for the care of a specific group of patients. A protocol is not a prescriptive order form like a standing order.

Question 3

3. The standing orders for a patient include acetaminophen (Tylenol) 650 mg every 4 hours prn for headache. After assessing the patient, identifying the need for headache relief, and determining that the patient has not had Tylenol in the past 4 hours, the nurse
   a.
   Notifies the health care provider to obtain a verbal order.
   b.
   Directs the nursing assistant to give the Tylenol.
   c.
   Administers the Tylenol.
   d.
   Performs a pain assessment only after administering the Tylenol.

Answer 3

ANS: C
A standing order is a preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identified clinical problems. Notifying the health care provider is not necessary if a standing order exists. The nursing assistant is not licensed to administer medications; therefore, medication administration should not be delegated to this person. A pain assessment should be performed before and after pain medication administration to assess the need for and effectiveness of the medication.

Question 4

4. Before implementing any intervention, the nurse uses critical thinking to
   a.
   Determine whether an intervention is correct and appropriate for the given situation.
   b.
   Evaluate the effectiveness of interventions.
   c.
   Establish goals for a particular patient without the need for reassessment.
   d.
   Read over the steps and perform a procedure despite lack of clinical competency.

Answer 4

ANS: A
Before implementing any intervention, the nurse uses critical thinking to determine whether an intervention is correct and appropriate for a clinical situation. The nurse cannot evaluate interventions until they are implemented. Patients need ongoing assessment because patient conditions can change very rapidly. The nurse needs to recognize the safety hazards of performing an intervention without clinical competency and seek assistance from another nurse.

Question 5

5. Which of the following is a nursing intervention?
   a.
   The patient will ambulate in the hallway twice this shift using crutches correctly.
   b.
   Impaired physical mobility related to inability to bear weight on right leg
   c.
   Provide assistance while the patient walks in the hallway twice this shift with crutches.
   d.
   The patient is unable to bear weight on right lower extremity.

Answer 5

ANS: C
Providing assistance to a patient who is ambulating is a nursing intervention. The statement, “The patient will ambulate in the hallway twice this shift using crutches correctly” is a patient goal. Impaired physical mobility is a nursing diagnosis. The statement that the patient is unable to bear weight and ambulate can be included with assessment data and is a defining characteristic for the diagnosis of Impaired physical mobility.

Question 6

6.	A patient recovering from a leg fracture after a fall states that he has dull pain in the affected leg and rates it as a 7 on a 0 to 10 scale. The patient is not able to walk around in the room with crutches because of leg discomfort. What is the priority nursing intervention for this patient?
a.
Assist the patient to walk in the room with crutches.
b.
Obtain a walker for the patient.
c.
Consult physical therapy.
d.
Administer pain medication.

Answer 6

ANS: D
The nurse clusters and organizes patient data, which leads to several nursing diagnoses. In this question, nursing diagnoses include Impaired physical mobility and Acute pain. Acute pain is the priority because the nurse can address the problem of immobility after the patient receives adequate pain relief. Assisting the patient to walk or obtaining a walker will not address the pain the patient is experiencing. When planning, the nurse needs to address the diagnosis of highest priority first.

Question 7

7. The nurse is caring for a patient who requires a complex dressing change. While in the patient’s room, the nurse decides to change the dressing. What does the nurse do just before changing the dressing?
   a.
   Assesses the patient’s readiness for the procedure
   b.
   Gathers and organizes needed supplies
   c.
   Decides on goals and outcomes for the patient
   d.
   Calls for assistance from another nursing staff member

Answer 7

ANS: A
The nurse needs to assess the patient’s readiness and willingness for any procedure before intervening. After determining the patient’s readiness for the dressing change, the nurse gathers needed supplies. The nurse establishes goals and outcomes before intervening. Before entering the patient’s room, the nurse needs to ask another staff member to help if necessary.

Question 8

8. A patient visiting with family members in the waiting area tells the nurse that his stomach is not feeling good. Before intervening, what should the nurse do?
   a.
   Ask the patient to return to his room so the nurse can inspect his abdomen.
   b.
   Request that the family leave, so the patient can rest.
   c.
   Ask the patient when his last bowel movement was and to lie down on the sofa.
   d.
   Tell the patient that his dinner tray will be ready in 15 minutes.

Answer 8

ANS: A
Assessment is the first step in the nursing process and needs to be completed before the nurse can intervene. In this case, the environment needs to be conducive to completing a thorough assessment. The patient needs to return to the room for an abdominal assessment for privacy and comfort. The family can remain in the waiting area while the nurse assists the patient back to the room. Beginning the assessment in the waiting area in the presence of family and other visitors does not promote privacy and patient comfort. Telling the patient that his dinner tray is almost ready is making an assumption that the abdominal discomfort is due to not eating. The nurse needs to perform an assessment first.

Question 9

9. A newly admitted patient who is morbidly obese asks the nurse to assist her to the bathroom for the first time. What should the nurse do first?
   a.
   Ask for at least two other assistive personnel to come to the room.
   b.
   Medicate the patient to alleviate discomfort while ambulating.
   c.
   Offer the patient a walker.
   d.
   Review the patient’s activity orders.

Answer 9

ANS: D
Before intervening, the nurse must check the patient’s orders. For example, if the patient is on bed rest, the nurse will need to explain the use of a bedpan rather than helping the patient get out of bed to go to the bathroom. Interventions sometimes will be determined by orders and availability of resources. Asking for assistive personnel is appropriate after making sure the patient can get out of bed. If the patient is obese, the nurse will likely need assistance in getting the patient to the bathroom. Medicating the patient before checking the orders is not advised in this situation. Before medicating for pain, the nurse needs to perform a pain assessment. Offering the patient a walker is a premature intervention until the orders are verified.

Question 10

10. Which of these interventions, to be included in the plan of care, is appropriate for the patient outcome that states, “The patient will verbalize a pain level at 3 or below on a 0 to 10 scale throughout this shift.”?
    a.
    Medicate the patient immediately after all procedures.
    b.
    Discuss only nonpharmacological methods of pain relief.
    c.
    Teach the patient about side effects of pain medications.
    d.
    Medicate the patient based on previous shift assessment findings.

Answer 10

ANS: C
The nurse needs to include teaching as an appropriate nursing intervention. Medicating the patient after procedures is not a helpful method of pain control. Patients need to be assessed for sign and symptoms of discomfort before and after procedures. The nurse discusses all options for pain relief, not just nonpharmacological methods. Patients’ needs can change from minute to minute, so basing an intervention on a previous shift assessment is incorrect.

Question 11

11.	What is the first intervention included on any patient’s plan of care?
a.
Determine patient outcomes and goals.
b.
Prioritize the patient’s nursing diagnoses.
c.
Reassess the patient.
d.
Assess for a patent airway.

Answer 11

ANS: C
Assessment is a continuous process that occurs each time the nurse interacts with a patient. During the initial phase of implementation, reassess the patient. Determining the patient’s goals and prioritizing diagnoses take place in the planning phase before choosing interventions. Assessing for a patent airway may or may not be a given patient’s first intervention, depending on the goals, priority diagnosis, and reassessment findings of the patient.

Question 12

12. Vital signs for a patient reveal a high blood pressure of 187/100. Orders state to notify the health care provider for diastolic blood pressure greater than 90. What is the nurse’s first action?
    a.
    Assess the patient for other symptoms or problems, and then notify the health care provider.
    b.
    Review the most recent lab results for the patient’s potassium level.
    c.
    Follow the clinical protocol for a stroke.
    d.
    Administer an antihypertensive medication from the stock supply, and then notify the health care provider.

Answer 12

ANS: A
The best answer is to briefly reassess the patient for other symptoms or problems, and then notify the health care provider according to the orders. Reviewing the potassium level does not address the problem of high blood pressure. The nurse does not make medical diagnoses, such as stroke. The nurse needs an order to administer medications.

Question 13

13. Which intervention is most appropriate for a patient who has a new onset of chest pain?
    a.
    Administer a prn medication for pain.
    b.
    Reassess the patient because of the change in condition.
    c.
    Notify the health care provider.
    d.
    Call radiology for a portable chest x-ray.

Answer 13

ANS: B
The cause of the patient’s chest pain is unknown, so the patient needs to be reassessed before pain medication is administered or a chest x-ray is obtained. The nurse then notifies the patient’s health care provider of the patient’s current condition in anticipation of receiving further orders. The patient’s chest pain could be due to muscular injury or a pulmonary issue. The nurse needs to reassess first.

Question 14

14. Which is the appropriate initial intervention for the nursing diagnostic statement Impaired skin integrity related to poor wound healing?
    a.
    Reinforce the wound dressing as needed with 4 × 4 gauze.
    b.
    Perform the ordered dressing change twice daily.
    c.
    Document wound characteristics.
    d.
    Assess wound appearance each shift

Answer 14

ANS: D
The most appropriate initial intervention is to assess the wound. Assessment guides the type and order of other interventions. The nurse must assess the wound first before the findings can be documented.

Question 15

15.	The nurse establishes trust and talks with a school-aged patient before administering injections. This nurse is demonstrating which type of implementation skill?
a.
Cognitive
b.
Interpersonal
c.
Psychomotor
d.
Judgmental

Answer 15

ANS: B
Nursing practice includes cognitive, interpersonal, and psychomotor skills. Cognitive involves the application of critical thinking and use of good judgment in making sound clinical decisions. Interpersonal skills involve developing trusting relationships with patients, conveying caring and compassion, and communicating clearly. Psychomotor skill requires the integration of cognitive and motor abilities. The nurse in this example displayed the interpersonal skills of establishing trust and talking with the patient before intervening.

Question 16

16.	The nurse inserts an intravenous catheter using the correct technique and following the recommended steps according to standards of care and hospital policy. This is demonstrating which type of implementation skill?
a.
Cognitive
b.
Interpersonal
c.
Psychomotor
d.
Judgmental

Answer 16

ANS: C
Nursing practice includes cognitive, interpersonal, and psychomotor skills. Psychomotor skill requires the integration of cognitive and motor abilities. Cognitive involves the application of critical thinking and use of good judgment in making sound clinical decisions. Interpersonal skills involve developing trusting relationships with patients, conveying caring and compassion, and communicating clearly. The nurse in this example displayed the psychomotor skill of inserting an intravenous catheter while following standards of care and integrating knowledge of anatomy and physiology.

Question 17

17. A nurse employed in a staff development department is providing an in-service for other nurses to educate them about the Nursing Interventions Classification (NIC) system. During the in-service, which of the following statements made by one of the nurses in the room requires the staff nurse to clarify the information provided?
    a.
    “This system can help medical students determine the cost of the care they provide.”
    b.
    “If the nursing department uses this system, communication among nurses who work throughout the hospital may be enhanced.”
    c.
    “We could use this system to help us better organize orientation for new nursing employees because we can better explain the nursing interventions we use most frequently on our unit.”
    d.
    “The NIC system provides one way to improve safe and effective documentation in the hospital’s electronic health record.”

Answer 17

ANS: A
The NIC system provides nurses the ability to determine the costs of services they provide. Because this system is specific to nursing practice, it would not help medical students determine the costs of care. Benefits of using NIC include enhancing communication among nursing staff and documentation, especially within health information systems such as an electronic documentation system. NIC also helps nurses identify the nursing interventions they implement most frequently. Units that identify routine nursing interventions can use this information to develop checklists for orientation.

Question 18

18.	The nurse is intervening for an identified nursing diagnosis of Caregiver role strain. Which direct care nursing intervention is most appropriate?
a.
Assisting with activities of daily living
b.
Counseling about respite care options
c.
Teaching range-of-motion exercises
d.
Emphasizing the importance of exercise

Answer 18

ANS: B
Respite care provides temporary assistance for family caring for someone with health care needs. The other options do not address the identified problem of caregiver role strain. Counseling is an example of a direct care nursing intervention.

Question 19

19. The nurse is intervening for an identified nursing diagnosis of Risk for infection. Which direct care nursing intervention is most appropriate?
    a.
    Teaching the family proper handwashing technique
    b.
    Leaving side rails up at all times
    c.
    Teaching the patient how to use crutches
    d.
    Counseling the family on stress reduction techniques

Answer 19

ANS: A
The only intervention listed that directly relates to preventing infection is teaching proper handwashing technique. Teaching is a direct care nursing intervention. Leaving the side rails up addresses patient safety. Teaching the patient how to use crutches pertains to mobility, and counseling the family is a health promotion activity intended to reduce stress, not decrease the risk for infection.

Question 20

1. Which of the following are nursing interventions? (Select all that apply.)
   a.
   Order chest x-ray for suspected humerus fracture.
   b.
   Order antibiotics for a respiratory infection.
   c.
   Reposition a patient who is on bed rest.
   d.
   Remind a patient to cough and deep breathe after surgery.
   e.
   Write transfer orders to move a patient to another hospital unit.

Answer 20

ANS: C, D
A nursing intervention is defined as any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes. Repositioning a patient and encouraging coughing and deep breathing are examples of nursing interventions. Ordering a chest x-ray, ordering antibiotics, and writing transfer orders are examples of medical interventions performed by a health care provider.

Question 21

2.	Which of the following are direct care interventions? (Select all that apply.)
a.
Turning a patient
b.
Counseling a patient
c.
Performing resuscitation
d.
Documenting wound care
e.
Teaching wound care

Answer 21

ANS: A, B, C, E
All of the interventions listed are direct care interventions involving patient and nurse interaction, except documenting wound care. Documenting wound care is an example of an indirect intervention.

Question 22

3.	Before implementing care, the nurse needs to ensure that which resources are available? (Select all that apply.)
a.
Equipment
b.
Safe environment
c.
Patient readiness
d.
Assistive personnel
e.
Creativity

Answer 22

ANS: A, B, C, D
Organization of equipment and personnel makes timely, efficient, skilled patient care possible. The nurse needs to assess the patient for readiness before implementing care. The nurse also needs to ensure that the environment is safe before implementing care. Creativity is needed to provide safe and effective patient care; however, creativity is a critical thinking attitude, not a resource.

Question 23

4. Which interventions are appropriate for the nursing diagnosis Impaired tissue integrity related to poor wound healing secondary to diabetes? (Select all that apply.)
   a.
   Teach the patient about signs and symptoms of infection.
   b.
   Help the patient cope with changes in body image that result from the wound.
   c.
   Perform dressing changes twice a day as ordered.
   d.
   Administer medications to control the patient’s blood sugar as ordered.
   e.
   Teach the family how to perform dressing changes.

Answer 23

ANS: A, C, D, E
The cause of the problem is poor wound healing secondary to diabetes. Nursing priorities include interventions directed at enhancing wound healing. Teaching the patient about signs and symptoms of infection will help the patient identify signs of appropriate wound healing and know when the need for calling the health care provider arises. Performing dressing changes, controlling blood sugars through administration of medications, and involving the family in dressing changes all contribute to wound healing. Although the patient possibly has altered body image related to the wound, counseling the patient about coping strategies addresses body image, not wound healing.