Chapter 19: Implementing Flashcards
A nurse is providing nursing care to patients after completing a care plan from nursing diagnoses. In which step of the nursing process is the nurse?
Implementation
The nurse is teaching a new nurse about protocols. Which information from the new nurse indicates a correct understanding of the teaching?
Protocols assist the clinician in making decisions and choosing interventions for specific health care problems and conditions.
The standing orders for a patient include acetaminophen 650 mg every 4 hours prn for headache. After assessing the patient, the nurse identifies the need for headache relief and determines that the patient has not had acetaminophen in the past 4 hours. Which action will the nurse take next?
Administer the acetaminophen.
Which action indicates a nurse is using critical thinking for implementation of nursing care to patients?
Determines whether an intervention is correct and appropriate for the given situation
A nurse is reviewing a patient’s care plan. Which information will the nurse identify as a nursing intervention?
Provide assistance while the patient walks in the hallway twice this shift with crutches.
A patient recovering from a leg fracture after a fall reports having 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. Which nursing intervention is priority?
Administer pain medication.
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. Which action will the nurse take just before changing the dressing?
Assesses the patient’s readiness for the procedure
A patient visiting with family members in the waiting area tells the nurse “I don’t feel good, especially in the stomach.” What should the nurse do?
Ask the patient to return to the room, so the nurse can inspect the abdomen.
A newly admitted patient who is morbidly obese asks the nurse for assistance to the bathroom for the first time. Which action should the nurse take initially?
Review the patient’s activity orders.
A new nurse is working in a unit that uses interdisciplinary collaboration. Which action will the nurse take?
Develop good communication skills.
Which action should the nurse take first during the initial phase of implementation?
Reassess the patient.
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?
Assess the patient for other symptoms or problems, and then notify the health care provider.
Which initial intervention is most appropriate for a patient who has a new onset of chest pain?
Reassess the patient.
A nurse is making initial rounds on patients. Which intervention for a patient with poor wound healing should the nurse perform first?
Observe wound appearance and edges.
The nurse establishes trust and talks with a school-aged patient before administering an injection. Which type of implementation skill is the nurse using?
Interpersonal
