Ch. 9

Question 1

What should the nurse consider before implementation of all nursing interventions?

Answer 1

Potential communication barriers.
Diverse cultural practices.
Scope of nursing practice.
Functional status of the patient

Question 2

Which intervention would be most important for the nurse to include in the care plan if the patient is unable to complete activities of daily living without becoming fatigued?

Answer 2

Encourage the patient to rest between activities

Question 3

Which nursing intervention is most important to complete before giving medication to a patient?

Answer 3

Double check the patients allergies before giving the drug

Question 4

Which direct care intervention would be most effective in helping a patient cope emotionally with a new diagnosis of cancer?

Answer 4

Encouraging the patient to explore options for care

Question 5

What should be taken into consideration by the nurse when deciding on interventions to include in a patient’s plan of care?

Answer 5

Patients treatment preferences.
Cultural and ethnic influences.
Professional level of expertise.
Current evidence based research

Question 6

Which task may the RN safely delegate to a UAP without prior intervention?

Answer 6

Transporting a patient to the hospital entrance for discharge.

Question 7

Which actions are a part of the evaluation step in the nursing process?

Answer 7

Recognizing the need for modifications to the care plan.

Reviewing whether a patient met the short term goal

Question 8

Which action by the day shift nurse provides objective data that enables the night shift nurse to complete an evaluation of a patients short term goals?

Answer 8

Documenting patient assessment findings in the patients chart

Question 9

Which notation is most appropriate for the nurse to include in a patients chart regarding evaluation of the goal, “patient will ambulate three times daily in the hallway before discharge without shortness of breath (SOB)?”

Answer 9

Goal met; patient ambulated three times in the hallway without SOB.

Question 10

What is the primary purpose of quality improvement?

Answer 10

Enhancing current practice to improve patient outcomes and care

Question 11

Describe the relationship between care plan modification and quality improvement

Answer 11

Care plan modification is based on the effectiveness of interventions to meet and improve desired patient outcomes.
QI processes benefit patients and ultimately affect patient care.
If certain patient outcomes are consistently improved by the implementation of specific nursing interventions, procedures can be changed on the basis of the QI research.

Question 12

Apply evaluation principles used in the nursing process

Answer 12

Evaluation focuses on the patient and the patients response to nursing interventions and outcome attainment.
Evaluation is not a record of the care that was implemented.
Info on the effectiveness of nursing interventions is a by-product of the evaluation process.
Nurses use critical thinking to determine whether a patients short and long term goals were med and the desired outcomes were achieved.

Question 13

Identify the significance of documentation in the implementation step

Answer 13

Nurses must document effectively to convey information accurately to other care providers.
Within HIPAA guidelines, patient documentation is provided to insurance companies and others for billing and reimbursement

Question 14

Recognize dependent nursing interventions

Answer 14

Tasks the nurse undertakes that are within the nursing scope of practice but require physician orders. Required to pay strict attention to the details of what was ordered and to recognize when implementing a dependent nursing intervention is appropriate or should be withheld in consultation

Question 15

Identify examples of independent nursing interventions

Answer 15

Tasks within the nursing scope of practice that don’t require physician orders.
Extent to which nurses can implement independent interventions is determined by the area in which care is taking place

Question 16

Differentiate among various forms of indirect care interventions

Answer 16

Indirect care includes nursing interventions performed to benefit patients without face to face contact.
Includes communicating and collaborating with other health care team members, making referrals, doing research, advocating, delegating and engaging in preventive actions (patient education and health promotion)

Question 17

Describe different types of direct care interventions

Answer 17

Direct care refers to interventions that are carried out by having personal contact with patients.
Direct nursing interventions include reassessing patients, assisting with ADLs, giving physical care, counseling and teaching.

Question 18

Explain the significance of implementation and evaluation in the nursing process

Answer 18

Nurses and other members of the health team provide care through interventions designed to promote, maintain, or restore a patients health during the implementation phase.
Consists of performing a task and documenting each intervention.
Evaluation focuses on the patient and patients response to nursing interventions and outcome attainment.
Eval data are used by the nurse to adapt a plan of care on the basis of patients changing health status.

Question 19

QI quality improvement

Answer 19

Formal way to look at patient and treatment outcomes and to determine what can be done differently to affect a situation in a positive way.
Benefits patients and ultimately affect patient care

Question 20

Care plans should…

Answer 20

Be updated regularly after patient evals.

Ongoing in an attempt to meet patient needs.

Question 21

If patient goals are not achieved the nurse reflects on:

Answer 21

What barriers did the patient have in meeting these goals?
Were the goals realistic?
What happened that was not anticipated?
What can be done differently?

Question 22

Reassessment should occur…

Answer 22

Every time the nurse interacts with a patient or reviews updated diagnostic lab tests

Question 23

Goal attainment and changing circumstances

Answer 23

reasons why plan of care is discontinued

Question 24

Revised or adapted

Answer 24

When patient goal is unmet or partially met

Question 25

When complications arise or goals are not met…

Answer 25

The nurse revises the plan of care in response to the eval findings

Question 26

Evaluation process begins…

Answer 26

With determining whether patient goals have been met.

Evaluation examines the extent to which interventions affected patient outcomes

Question 27

Medical treatments

Answer 27

Dependent nursing interventions
Ex. Urinary catheterization, 24 hour urine collection, dressing changes, incision irrigation, intubation, and placing NG tubes

Question 28

Medication administration

Answer 28

Within scope of nursing practice but is dependent.
Nurses must omelet three checks and follow 6 rights of med administration.
Check physicians order, patient allergies, and expiration date

Question 29

6 rights of medication administration

Answer 29

• right medication
• right dosage
• correct route
• right patient
• right time
• correct documentation

Question 30

Standing orders

Answer 30

Preapproved.
Ex. Patient return to room after cardiac catheterization, standing order is that the patient remains on bed rest for specific amount of time. The nurse is to maintain patient on bed rest for requested amount of time

Question 31

Informal counseling

Answer 31

Provide a listening ear.
Stimulate patients thought process or decision making process.
May occur when faced with new diagnosis

Question 32

Physical care

Answer 32

Performed when treating patients.

Invasive/noninvasive procedures

Question 33

ADLs

Answer 33

Activities of daily living
Important to assess where deficits exist and determine whether patients require short or long term interventions to address their needs

Question 34

Reassessment

Answer 34

Continuous to detect noticeable changes in condition, and adjustments to current interventions.

Question 35

Direct care

Answer 35

Interventions that are carried out by having personal contact with patients

Question 36

Implementation

Answer 36

Consists of performing a task

Question 37

Teaching

Answer 37

Essential professional nursing intervention.

Each interaction with a patient is an opportunity to teach

Question 38

Indirect care

Answer 38

Performed for patients but do not involve face to face contact with patient

Question 39

Communication and collaboration

Answer 39

Essential for patient safety and positive patient outcomes

Question 40

Referrals

Answer 40

Involve sending a patient to another member of the health care team or agency for consultation

Question 41

Research

Answer 41

Evidence based care involves interventions provided by all members of health care team

Question 42

Advocacy

Answer 42

Supporting and working on behalf of the patient or people for whom they have concern

Question 43

Delegation

Answer 43

Transfer of responsibility for performing a task to another person while the nurse who delegated is held accountable.
Indirect intervention

Question 44

Prevention oriented interventions

Answer 44

Prevent illness or complications and promote healthy activities or lifestyles