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Chapter-019 test bank
Fundamentals I (NR224)
Chamberlain University
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Potter & Perry: Fundamentals of Nursing, 7th Edition
Test Bank
Chapter 19: Implementing Nursing Care
MULTIPLE CHOICE
- The nurse is working with postoperative clients on a surgical unit. One aspect of care is manipulation of the client’s environment. This involves the nurse:
- Repositioning the client q2h
- Removing clutter from the client’s room
- Delegating ambulation of clients to the nursing assistant
- Providing pain medication to the client before a dressing change
ANS: 2 Making rooms free of clutter is an example of manipulating the environment to create safe surroundings. The remaining options are examples of the organization of care and personnel.
DIF: A REF: 282 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Safe, Effective Care Environment
- The client is given an injection of an antibiotic. Shortly afterwards the client reports hives and itching. The nurse administers an antihistamine to counteract the effect of the antibiotic. The nurse is using which one of the following intervention methods?
- Preventive measures
- Assisting with ADLs
- Preparing for special procedures
- Compensation for adverse reactions
ANS: 4 Nursing actions that control for adverse reactions reduce or counteract the reaction, such as administering an antihistamine after an allergic reaction to a medication. Preventive measures promote health and prevent illness while assisting with ADLs and preparing for special procedures are direct care measures.
DIF: A REF: 283-284 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Safe, Effective Care Environment
The client is scheduled to receive Coumadin (an anticoagulant) at 9:00 AM. His morning laboratory results show him to have a high partial thromboplastin time (PTT). His nurse decides to withhold the Coumadin. Which step of the implementation process is she using?
Reassessing the client
Stating an expected outcome
Revising the nursing diagnosis
Modifying the nursing care plan
ANS: 4 The nurse is modifying the nursing care plan. Data have been updated to reflect the client’s current status of an elevated PTT; nursing diagnoses and specific interventions are revised. In this case, the revised intervention is withholding the Coumadin. By gathering further assessment data and revising nursing interventions, the nurse is modifying the nursing care plan.
DIF: A REF: 282 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Safe, Effective Care Environment
- The nurse notes that a narcotic is to be administered “per epidural cath.” The nurse; however, does not know how to perform this procedure. Which aspect of the implementation process should be followed?
- Seek assistance
- Reassess the client
- Use interpersonal skills
- Critical decision making
ANS: 1 If a nurse does not know how to perform a procedure, he or she should seek assistance. Information about the procedure is obtained from the literature and the agency’s procedure book. All equipment necessary for the procedure is collected. Finally, another nurse who has completed the procedure correctly and safely provides assistance and guidance. Reassessing the client is a partial assessment that may focus on one dimension of the client or on one system. Interpersonal skills are used to develop a trusting relationship, express a level of caring, and communicate clearly with the client, family, and health care team. Critical decision making is used when the nurse implements the care plan using the knowledge bases necessary for care planning and then completing the planned interventions most effectively.
DIF: A REF: 284 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Safe, Effective Care Environment
- The nurse recognizes the discharge needs of a client following a hip replacement. This is an example of which type of nursing skill?
- Cognitive
- Interactive
- Psychomotor
- Communication
ANS: 1
Psychomotor skills involve the integration of cognitive and motor activities, such as in providing ostomy care. Cognitive skills involve the application of nursing knowledge. Knowing the rationale for therapeutic interventions, understanding normal and abnormal physiological and psychological responses, and being able to identify client learning and discharge needs all require cognitive skills. Interpersonal skills are used when the nurse interacts with clients, their families, and other health care team members. Effective communication is an example of an interpersonal skill. Affective means pertaining to an emotion or mental state.
DIF: A REF: 284 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Safe, Effective Care Environment
- For a client with a nursing diagnosis of impaired physical mobility related to bilateral arm casts, the nurse should select which of the following methods of nursing intervention?
- Teaching
- Counseling
- Compensating for adverse reactions
- Assisting with activities of daily living (ADLs)
ANS: 4 A client with bilateral arm casts has a temporary need for assistance with ADLs. Counseling is a direct care method that helps the client use a problem-solving process to develop new attitudes and feelings. It does not meet the physical need for assistance with ADLs. Teaching is an implementation method used to present correct principles, procedures, and techniques of health care to clients and to inform clients about their health status. Compensating for adverse reactions means the nurse takes action to reduce or counteract the reaction, such as by administering an antihistamine when a client has an allergic reaction to a medication. Assisting with ADLs would be compensating for the client’s impaired mobility.
DIF: A REF: 285 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Safe, Effective Care Environment
- The plan of care offers a number of different types of nursing interventions that may be incorporated in. An example of a nurse implemented specific life-saving measure is:
- Administering analgesics
- Restraining a violent client
- Initiating stress-reduction therapy
- Teaching the client how to take his/her pulse rate
ANS: 2
Restraining a violent client is an example of a life-saving measure to protect the client. The purpose of a life-saving measure is to restore physiological or psychological equilibrium. Administering analgesics is an example of physical care techniques. It is not a life-saving measure. Initiating stress-reduction therapy is an example of a counseling technique. Teaching the client how to take his or her pulse rate is an example of the nursing intervention of teaching. The focus is for the client to obtain new knowledge or psychomotor skills.
DIF: A REF: 285 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Safe, Effective Care Environment
- To provide optimum care, a nursing intervention should be based on:
- An appropriate nursing diagnosis
- Subjective and objective client data
- Sound clinical judgment and knowledge
- Identified physical and psychosocial needs of the client
ANS: 3 The assessment data direct the nurse in the formulation of a client-specific care plan grounded within clear, relevant nursing diagnoses and directed towards appropriate, attainable client outcomes. A nursing intervention is any treatment, based upon clinical judgment and knowledge that a nurse performs to enhance client outcomes. Ideally, the interventions a nurse uses are evidence-based, providing the most current, up-to-date, and effective approaches for client problems. Interventions include both direct and indirect care measures, aimed at individuals, families, and/or the community.
DIF: C REF: 279 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Safe, Effective Care Environment
- Which of the following interventions is the best example of an indirect intervention directed towards client safety?
- Checking on a restrained client every 15 minutes
- Performing hand hygiene between client contacts
- Including the diagnosis at risk for injury related to falls to a client’s care plan
- Turning on a night light to illuminate the path to the bathroom
ANS: 4
Licensed prescribing physicians or health care providers in charge of care at the time of implementation approve and sign standing orders. These orders are common in critical care settings and other specialized practice settings where clients’ needs change rapidly and require immediate attention, thus providing for nursing autonomy to assess and implement appropriate care.
DIF: C REF: 281 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Safe, Effective Care Environment
- Which of the following statements best reflects the nurse’s understanding of the function of client reassessment?
- “The client’s blood pressure is lower this morning than it was yesterday morning.”
- “30 minutes after receiving his pain medication, the client evaluated his pain at 3 out of 10.”
- “Turning the client every 2 hours has helped in the healing of the pressure ulcer on his coccyx.”
- “Since the client has been ambulating to the bedroom without difficulty, I’ll walk with him to the dayroom after dinner.”
ANS: 4 When reassessment results in the collection of new data that identify a new client need, the care plan is modified. Modification of a plan also occurs when a client’s health care need shows improvement or is resolved. The other options reflect recognition of a change in the client’s condition but do not reflect an alteration of the care plan.
DIF: C REF: 281-282 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Safe, Effective Care Environment
- Which of the following statements made by a nurse practitioner best reflects an understanding of the availability of clinical practice guidelines?
- “Clinical guidelines are so very helpful in providing the most up-to-date nursing care.”
- “I’m sure we could get a team together and develop a pressure ulcer prevention protocol or search sites for established protocols.”
- “I am particularly impressed by the type 2 diabetic guidelines posted on the National Guidelines Clearinghouse (NGC) site.”
- “I’m told that for gerontological issues, the Gerontological Nursing Interventions Research Center (GNIRC) is the primary resource site.”
ANS: 3 There are clinical practice guidelines already developed by national health groups. These guidelines are readily available to any clinician or health care institution that wishes to adopt evidence-based guidelines in the care of clients with specific health problems. The best option reflects the nurse’s personal experience with a published protocol.
DIF: C REF: 281 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Safe, Effective Care Environment
- The fundamental goal for the development of a protocol for care of a client who has had a myocardial infarction client is to:
- Implement care that has its basis in evidence-based practice
- Produce care plans that are specific to the individual client needs
- Improve the standard of care provided to the clients cared for on that unit
- Provide the staff on that unit with guidelines to ensure the delivery of quality care
ANS: 3 Clinicians within a health care agency sometimes choose to review the scientific literature and their own standard of practice to develop guidelines and protocols in an effort to improve their standard of care. All the other options are potential outcomes of the implementation of a protocol.
DIF: C REF: 281 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Safe, Effective Care Environment
- Which of the following nursing actions is most likely a result of the nurse’s clinical experience?
- Placing an immobile client on a turning schedule
- Always assessing a client’s IV site before hanging a new bag of fluid
- Requesting that the nursing assistant have vital signs recorded by 0815
- Administering a pain medication 30 minutes before changing a burn dressing
ANS: 2 As a nurse gains clinical experience, he or she will be able to consider which interventions have worked previously, which have not, and why. The decision to check each IV site has become a practice standard for this nurse as a result of previous experiences with IV sites. The remaining options are either standards of care or facility/unit standards.
DIF: C REF: 280 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Safe, Effective Care Environment
- Which of the following statements made by a new nursing graduate requires immediate follow-up by the nurse’s mentor?
- “Older clients with arthritis require additional time to complete to complete their own AM care.”
- “My client’s wife says he loves chocolate milk so I will order his dietary supplement in chocolate.”
- “My client just received some bad news regarding her tests. I’ll see if the chaplain can visit this evening.”
DIF: C REF: 282 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Safe, Effective Care Environment
- Which of the following statements regarding utilization of personnel made by a new graduate nurse requires immediate follow-up by the nurse’s mentor?
- “My LPN is really good with dressings, so I usually delegate them to her.”
- “I always take the time to ambulate a post op client the first time out of bed.”
- “I always try to help my nursing assistant with the clients who require a total bed bath.”
- “I have my nursing assistant take and document all vital signs and intake and outputs.”
ANS: 4 The nurse is responsible for determining whether to perform an intervention or to delegate it to another member of the nursing team. Assessment of a client directs the decision about delegation and not the intervention alone. Vital signs are important indicators of a client’s health status and the task should be delegated to ancillary personnel only when the client is in a stable condition; otherwise, the nurse should be responsible. The other options reflect responsible assignment of personnel.
DIF: C REF: 287 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Safe, Effective Care Environment
Chapter-019 test bank
Course: Fundamentals I (NR224)
University: Chamberlain University
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