Chapter 19 Implementing Nursing Care

Question 0

1. The nurse enters a patient’s room and finds that the patient was incontinent of liquid stool. The patient has recurrent redness in the perineal area, and there is concern that he is developing a pressure ulcer. The nurse cleanses the patient, inspects the skin, and applies a skin barrier ointment to the perineal area. She calls the ostomy and wound care specialist and asks that he visit the patient to recommend skin care measures. Which of the following describe the nurse’s actions? (Select all that apply.)

A. The application of the skin barrier is a dependent care measure.
B. The call to the ostomy and wound care specialist is an indirect care measure.
C. The cleansing of the skin is a direct care measure.
D. The application of the skin barrier is a direct care measure.

Answer 0

B, C and D

Rationale:
The call to the ostomy and wound care specialist is an indirect care measure involving collaborative care. Cleansing the skin is an independent direct care measure. Applying the skin barrier is an independent nursing measure involving direct care.

Question 1

2. A nurse checks a physician’s order and notes that a new medication was ordered. The nurse is unfamiliar with the medication. A nurse colleague explains that the medication is an anticoagulant used for postoperative patients with risk for blood clots. The nurse’s best action before giving the medication is to:

A. Have the nurse colleague check the dose with her before giving the medication.
B. Consult with a pharmacist to obtain knowledge about the purpose of the drug, the action, and the potential side effects.
C. Ask the nurse colleague to administer the medication to her patient.
D. Administer the medication as prescribed and on time.

Answer 1

B

Rationale:
When a nurse performs a new or unfamiliar procedure, such as giving a new medication, it is important to assess personal competency and determine if new knowledge or assistance is needed. The nurse’s best action is to check with the pharmacist about the medication. Having another nurse check the dosage is appropriate if the nurse is still uncertain about the medication. Once the nurse feels prepared, the medication is administered as prescribed. You never ask a colleague to give a medication to a patient to whom you are assigned.

Question 2

3. When does implementation begin as the fourth step of the nursing process?

A. During the assessment phase
B. Immediately in some critical situations
C. After the care plan has been developed
D. After there is mutual goal setting between nurse and patient

Answer 2

C

Rationale:
Implementation begins after the nurse has developed the plan of care. Even in emergent situations a nurse assesses a situation quickly, considers options, and then implements nursing measures. Goal setting is part of planning.

Question 3

4. Before consulting with a physician about a patient’s need for urinary catheterization, the nurse considers the fact that the patient has urinary retention and has been unable to void on her own. The nurse knows that evidence for alternative measures to promote voiding exists, but none has been effective, and that before surgery the patient was voiding normally. This scenario is an example of which implementation skill?

A. Cognitive
B. Interpersonal
C. Psychomotor
D. Consultative

Answer 3

A

Rationale:
Thinking and anticipating how to approach implementation involve a cognitive implementation skill. The nurse considers the rationale for an intervention and evidence in nursing science that supports that intervention or alternatives.

Question 4

5. The nurse enters a patient’s room, and the patient asks if he can get out of bed and transfer to a chair. The nurse takes precautions to use safe patient handling techniques and transfers the patient. This is an example of which physical care technique?

A. Meeting the patient’s expressed wishes
B. Indirect care measure
C. Protecting a patient from injury
D. Staying organized when implementing a procedure

Answer 4

C

Rationale:
A common method for administering physical care techniques appropriately includes protecting you and your patients from injury, which involves safe patient handling. Transferring a patient is a direct care measure. Organization is an aspect of physical care but not an example of this nurse’s action. Although meeting patient needs is important, it is not a physical care technique.

Question 5

6. In which of the following examples is a nurse applying critical thinking attitudes when preparing to insert an intravenous (IV) catheter? (Select all that apply.)

A. Following the procedural guideline for IV insertion
B. Seeking necessary knowledge about the steps of the procedure from a more experienced nurse
C. Showing confidence in performing the correct IV insertion technique
D. Being sure that the IV dressing covers the IV site completely

Answer 5

B and C

Rationale:
Seeking necessary knowledge about the steps of the procedure shows humility. The nurse recognizes that she needs clarification from a senior colleague. Another example of a critical thinking attitude is confidence. In this case confidently inserting an IV line allows the nurse to convey expertise and a sense of calm, leading the patient to trust the nurse. Following policy and procedure is an example of following standards of care, not of a critical thinking attitude. Making sure that the dressing is covered is a step in following good standards of IV care but is not a critical thinking attitude.

Question 6

7. Which steps does the nurse follow when he or she is asked to perform an unfamiliar procedure? (Select all that apply.)

A. Seeks necessary knowledge
B. Reassesses the patient’s condition
C. Collects all necessary equipment
D. Delegates the procedure to a more experienced staff member
E. Considers all possible consequences of the procedure

Answer 6

A,C and E

Rationale:
You require additional knowledge and skills in situations in which you are less experienced. When you are asked to administer a new procedure with which you are unfamiliar, follow the three choices: seek necessary knowledge, collect necessary equipment, and consider all possible consequences of the procedure. Collecting necessary equipment and considering potential consequences is needed for any procedure.

Question 7

8. A nurse is talking with a patient who is visiting a neighborhood health clinic. The patient came to the clinic for repeated symptoms of a sinus infection. During their discussion the nurse checks the patient’s medical record and realizes that he is due for a tetanus shot. Administering the shot is an example of what type of preventive intervention?

A. Tertiary
B. Direct care
C. Primary
D. Secondary

Answer 7

C

Rationale:
An immunization is an example of a primary prevention aimed at health promotion.

Question 8

9. A nurse is orienting a new graduate nurse to the unit. The graduate nurse asks, “Why do we have standing orders for cases when patients develop life-threatening arrhythmias? Is not each patient’s situation unique?” What is the nurse’s best answer?

A. Standing orders are used to meet our physician’s preferences.
B. Standing orders ensure that we are familiar with evidence-based guidelines for care of arrhythmias.
C. Standing orders allow us to respond quickly and safely to a rapidly changing clinical situation.
D. Standing orders minimize the documentation we have to provide.

Answer 8

C

Rationale:
Standing orders are preprinted documents containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identified clinical problems. They are common in critical care settings and other specialized practice settings in which patients’ needs change rapidly and require immediate attention.

Question 9

10. When a nurse properly positions a patient and administers an enema solution at the correct rate for the patient’s tolerance, this is an example of what type of implementation skill?

A. Interpersonal
B. Cognitive
C. Collaborative
D. Psychomotor

Answer 9

D

Rationale:
Psychomotor skills require the integration of cognitive and motor activities to ensure safe intervention.

Question 10

11. The nurse reviews a patient’s medical record and sees that tube feedings are to begin after a feeding tube is inserted. In recent past experiences the nurse has seen patients on the unit develop diarrhea from tube feedings. The nurse consults with the dietitian and physician to determine the initial rate that will be ordered for the feeding to lessen the chance of diarrhea. This is an example of what type of direct care measure?

A. Preventive
B. Controlling for an adverse reaction
C. Consulting
D. Counseling

Answer 10

B

Rationale:
Anticipating the need to start the feeding at a slower rate is an example of controlling for an adverse reaction, which in this case would be a harmful or unintended effect (diarrhea) of therapeutic intervention.

Question 11

12. A nurse is starting on the evening shift and is assigned to care for a patient with a diagnosis of impaired skin integrity related to pressure and moisture on the skin. The patient is 72 years old and had a stroke. The patient weighs 250 pounds and is difficult to turn. As the nurse makes decisions about how to implement skin care for the patient, which of the following actions does the nurse implement? (Select all that apply.)

A. Review the set of all possible nursing interventions for the patient’s problem
B. Review all possible consequences associated with each possible nursing action
C. Consider own level of competency
D. Determine the probability of all possible consequences

Answer 11

A, B and D

Rationale:
When making decisions about implementation, reviewing all possible interventions and consequences and determining the probability of consequences are necessary steps. The nurse is responsible for having the necessary knowledge and clinical competency to perform an intervention, but this is not part of the decision making involved.