TB Ch: 19 - Implementing Nursing Care (delegation, etc) 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?
a. Assessment
b. Planning
c. Implementation
d. Evaluation
ANS: C
Implementation, the fourth step of the nursing process, formally begins after a nurse develops a plan of care. With a care plan based on clear and relevant nursing diagnoses, a nurse initiates interventions that are designed to assist the patient in achieving the goals and expected outcomes needed to support or improve the patient’s health status. 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 achievement of goals and effectiveness of interventions.
The nurse is teaching a new nurse about protocols. Which information from the new nurse indicates a correct understanding of the teaching?
a. Protocols are guidelines to follow that replace the nursing care plan.
b. Protocols assist the clinician in making decisions and choosing interventions for specific health care problems or conditions.
c. Protocols are policies designating each nurse’s duty according to standards of care and a code of ethics.
d. Protocols are prescriptive order forms that help individualize the plan of care.
ANS: B
A clinical practice guideline or protocol is a systematically developed set of statements that helps nurses, physicians, and other health care providers make decisions about appropriate health care for specific clinical situations. This guideline establishes 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.
0The 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?
a. Administer the acetaminophen.
b. Notify the health care provider to obtain a verbal order.
c. Direct the nursing assistive personnel to give the acetaminophen.
d. Perform a pain assessment only after administering the acetaminophen.
ANS: A
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. The nurse will administer the medication. Notifying the health care provider is not necessary if a standing order exists. The nursing assistive personnel are 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
Which action indicates a nurse is using critical thinking for implementation of nursing care to patients?
a. Determines whether an intervention is correct and appropriate for the given situation
b. Reads over the steps and performs a procedure despite lack of clinical competency
c. Establishes goals for a particular patient without assessment
d. Evaluates the effectiveness of interventions
ANS: A
As you implement interventions, use critical thinking to confirm whether the interventions are correct and still appropriate for a patient’s clinical situation. You are responsible for having the necessary knowledge and clinical competency to perform interventions for your patients safely and effectively. The nurse needs to recognize the safety hazards of performing an intervention without clinical competency and seek assistance from another nurse. The nurse cannot evaluate interventions until they are implemented. Patients need ongoing assessment before establishing goals because patient conditions can change very rapidly.
A nurse is reviewing a patient’s care plan. Which information will the nurse identify as 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.
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 outcome. 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.
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?
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.
ANS: D
The patient’s pain is a 7, indicating the priority is pain relief (administer pain medication). 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.
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?
a. Gathers and organizes needed supplies
b. Decides on goals and outcomes for the patient
c. Assesses the patient’s readiness for the procedure
d. Calls for assistance from another nursing staff member
ANS: C
Always be sure a patient is physically and psychologically ready for any interventions or procedures. After determining the patient’s readiness for the dressing change, the nurse gathers needed supplies. The nurse establishes goals and outcomes before intervening. The nurse needs to ask another staff member to help if necessary after determining readiness of the patient.
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?
a. Request that the family leave, so the patient can rest.
b. Ask the patient to return to the room, so the nurse can inspect the abdomen.
c. Ask the patient when the last bowel movement was and to lie down on the sofa.
d. Tell the patient that the dinner tray will be ready in 15 minutes and that may help the stomach feel better.
ANS: B
In this case, the environment needs to be conducive to completing a thorough assessment. A patient’s care environment needs to be safe and conducive to implementing therapies. When you need to expose a patient’s body parts, do so privately by closing room doors or curtains because the patient will then be more relaxed; 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 (lie down on the sofa) in the presence of family and other visitors does not promote privacy and patient comfort. Telling the patient that the 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.
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?
a. Ask for at least two other assistive personnel to come to the room.
b. Medicate the patient to alleviate discomfort while ambulating.
c. Review the patient’s activity orders.
d. Offer the patient a walker.
ANS: C
Before beginning care, review the plan to determine the need for assistance and the type required. 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. 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.
A new nurse is working in a unit that uses interdisciplinary collaboration. Which action will the nurse take?
a. Act as a leader of the health care team.
b. Develop good communication skills.
c. Work solely with nurses.
d. Avoid conflict.
ANS: B
Good communication between other health care providers builds trust and is related to the acceptance of your role in the health care team. As a beginning nurse, you will not be considered a leader of the health care team, but your input as an interdisciplinary team member is critical. Interdisciplinary involves other health care providers, not just nurses. Organizational culture includes leadership, communication processes, shared beliefs about the quality of clinical guidelines, and conflict resolution.
Which action should the nurse take first during the initial phase of implementation?
a. Determine patient outcomes and goals.
b. Prioritize patient’s nursing diagnoses.
c. Evaluate interventions.
d. Reassess the patient.
ANS: D
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. Evaluation is the last step of the nursing process.
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 firstaction?
a. Follow the clinical protocol for a stroke.
b. Review the most recent lab results for the patient’s potassium level.
c. Assess the patient for other symptoms or problems, and then notify the health care provider.
d. Administer an antihypertensive medication from the stock supply, and then notify the health care provider.
ANS: C
Communication to other health care professionals must be timely, accurate, and relevant to a patient’s clinical situation. The best answer is to 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 follow the protocol since the order says to notify the health care provider. The orders read to notify the health care provider, not administer medications.
Which initial intervention is most appropriate for a patient who has a new onset of chest pain?
a. Reassess the patient.
b. Notify the health care provider.
c. Administer a prn medication for pain.
d. Call radiology for a portable chest x-ray.
ANS: A
Preparation for implementation ensures efficient, safe, and effective nursing care; the first activity is reassessment. 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.
A nurse is making initial rounds on patients. Which intervention for a patient with poor wound healing should the nurse perform first?
a. Reinforce the wound dressing as needed with 4 × 4 gauze.
b. Perform the ordered dressing change twice daily.
c. Observe wound appearance and edges.
d. Document wound characteristics.
ANS: C
The most appropriate initial intervention is to assess the wound (observe wound appearance and edges). The nurse must assess the wound first before the findings can be documented, reinforcement of the dressing, and the actual skill of dressing changes.
The nurse establishes trust and talks with a school-aged patient before administering an injection. Which type of implementation skill is the nurse using?
a. Cognitive
b. Interpersonal
c. Psychomotor
d. Judgmental
ANS: B
Nursing practice includes cognitive, interpersonal, and psychomotor skills. Interpersonal skills involve developing trusting relationships with patients, conveying caring and compassion, and communicating clearly. Cognitive skills include critical thinking and decision-making skills. Psychomotor skill requires the integration of cognitive and motor abilities, such as administering the injection. Being judgmental is not appropriate in nursing; nurses are nonjudgmental.
