- Which of the following nursing interventions is an indirect-care intervention?
| a) | Emotional support |
| b) | Teaching |
| c) | Consulting |
| d) | Physical care |
ANS: C
An indirect-care intervention is an activity performed away from the client on behalf of the client. Indirect-care interventions include consulting with other healthcare team members, making referrals, advocating, and managing the environment. Direct-care interventions include emotional support, patient teaching, and physical care.
Difficulty: Easy
Nursing Process: Implementation
Client Need: Safe and Effective Nursing Care
Cognitive Level: Comprehension
PTS: 1
- A nurse makes a nursing diagnosis of Acute Pain related to the postoperative abdominal incision. She writes a nursing order to reposition the client in a comfortable position using pillows to splint or support the painful areas. What type of nursing intervention did the nurse write?
| a) | Collaborative |
| b) | Interdependent |
| c) | Dependent |
| d) | Independent |
ANS: D
Writing an order to reposition the client in a comfortable position is an example of an independent nursing intervention, one that does not require a physician’s order. The nurse is licensed to prescribe, perform, or delegate the intervention based on her knowledge and skills. A collaborative or interdependent intervention is one that is carried out in collaboration with other health team members, such as providing the client with a sodium-restricted diet. A dependent intervention is prescribed by a physician or advanced practice nurse, for example, “Administer oxygen at 2 L/min via nasal cannula.”
Difficulty: Moderate
Nursing Process: Implementation
Client Need: PHY
Cognitive Level: Application
PTS: 1
- The nurse is performing preoperative teaching for a client who is scheduled for surgery in the morning. The client does not at present have any respiratory problems. The nurse’s teaching plan includes coughing and deep-breathing exercises. Which type of nursing intervention is the nurse performing?
| a) | Health promotion |
| b) | Treatment |
| c) | Prevention |
| d) | Assessment |
ANS: C
The nurse is teaching the client coughing and deep-breathing exercises, which help prevent postoperative pneumonia. Therefore, the nurse is employing a prevention intervention. Prevention interventions are used to help prevent complications, such as postoperative pneumonia. Health promotion interventions promote a client’s efforts to achieve a higher level of wellness. Treatment interventions treat disorders, relieve symptoms, and carry out medical orders. Assessment interventions detect changes in the client’s condition and detect potential problems.
Difficulty: Moderate
Nursing Process: Interventions
Client Need: PHSI
Cognitive Level: Application
PTS: 1
- A 55-year-old patient returned to the medical-surgical unit after undergoing a right hemicolectomy (abdominal surgery) for colon cancer. Which of the following is an appropriate, correctly written nursing order for this patient?
| a) | 7/12/15 Encourage use of the incentive spirometer every hour while the client is awake—D. Goodman, RN |
| b) | By 7/12/15, uses incentive spirometer 10 times every hour while awake to 1,000 mL |
| c) | Incentive spirometer hourly while awake |
| d) | Offer incentive spirometer to the client—J. Smith, RN |
ANS: A
The option beginning with a date and ending with the RN’s signature contains necessary information. It contains the date the order was written along with specific instruction for the nurse that is written in terms of nursing behavior. “Uses incentive spirometer 10 times . . .” is an example of an expected outcome. “Incentive spirometer hourly . . .” is an example of a medical order. In this case, the date and nurse’s signature are missing. “Offer incentive spirometer . . .” does not provide the nurse with enough detailed instruction. Therefore, it is a poorly written nursing order.
Difficulty: Moderate
Nursing Process: Planning
Client Need: PHSI
Cognitive Level: Application
PTS: 1
- A client newly diagnosed with diabetes is admitted to the hospital because her diabetes is out of control. Which of the following is an appropriate direct-care intervention for this client during her stay?
| a) | Consulting the diabetic nurse educator for help with a teaching plan |
| b) | Making arrangements for the client to join a diabetic support group |
| c) | Demonstrating blood glucose monitoring and insulin administration to the client |
| d) | Consulting with the dietician about the client’s dietary concerns |
ANS: C
Demonstrating blood glucose monitoring and insulin administration is an appropriate direct-care intervention for this client. Direct-care interventions are performed through intervention with the client and include interventions such as physical care, emotional support, and client teaching. Indirect-care activities include consulting the diabetic nurse educator, making arrangements for the client to join a diabetic support group, and consulting with the dietitian about the client’s dietary concerns. Indirect-care activities are performed away from the client but on behalf of the client.
Difficulty: Moderate
Nursing Process: Interventions
Client Need: Physiological Integrity
Cognitive Level: Application
PTS: 1
- Which definition best describes a critical pathway?
| a) | Standardized plan of care for frequently occurring conditions |
| b) | Systematically developed statement to assist practitioners and patients in decision making |
| c) | Systematic review of clinical evidence for an intervention |
| d) | Set of interrelated concepts that describes or explains something |
ANS: A
Critical pathways are standardized plans of care for commonly occurring health conditions (e.g., myocardial infarction) for which similar outcomes and interventions are appropriate for the majority of patients with the condition. Clinical practice guidelines are systematically developed statements to assist practitioners and patients in making decisions about appropriate healthcare for a particular disease or procedure. Evidence reports are systematic reviews of clinical topics for the purpose of providing evidence for guidelines, quality improvement, quality measures, and insurance coverage decisions. A theory is a set of interrelated concepts that describe or explain something.
Difficulty: Easy
Nursing Process: Planning
Client Need: Safe and Effective Nursing Care
Cognitive Level: Knowledge
PTS: 1
- A client is admitted to the hospital with an acute respiratory problem resulting from lung disease. The nurse makes a diagnosis of Ineffective Breathing Pattern related to inability to maintain adequate rate and depth of respirations. Which nursing intervention should be listed first on the care plan?
| a) | Determine airway adequacy hourly and as needed. |
| b) | Administer oxygen as needed. |
| c) | Monitor arterial blood gas values. |
| d) | Place the client in a high Fowler’s position. |
ANS: A
For any acute respiratory problem, prior to implementing interventions the nurse would assess breathing status of the patient by checking the respiratory rate and depth. When devising a plan of care for the client, nursing interventions should be listed according to priority. Airway always takes precedence, as ventilation, oxygenation, and positioning will be ineffective without a patent airway.
Difficulty: Difficult
Nursing Process: Planning
Client Need: PHSI
Cognitive Level: Analysis
PTS: 1
- Who is the primary decision maker when caring for healthy adult clients?
| a) | Provider |
| b) | Family |
| c) | Client |
| d) | Nurse |
ANS: C
The client is the primary decision maker in the care of healthy clients. The nurse functions as a teacher and health counselor. The provider plays a role in health promotion and screening. The family may give input, but the client is the decision maker.
Difficulty: Easy
Nursing Process: Planning
Client Need: HPM
Cognitive Level: Comprehension
PTS: 1
- A client is admitted to the hospital with an acute episode of chronic obstructive pulmonary (lung) disease. The nurse makes a diagnosis of Ineffective Breathing Pattern related to inability to maintain adequate rate and depth of respirations and has recorded the diagnosis and appropriate goals on the care plan. When selecting nursing interventions, what should the nurse do first?
| a) | Identify several interventions likely to achieve the desired outcomes. |
| b) | Review the problem and etiology of the nursing diagnosis. |
| c) | Choose the best interventions for the patient. |
| d) | Review the goals she has written. |
ANS: B
The process of choosing interventions is first to review the nursing diagnosis and etiology; then review the desired outcomes; identify several interventions or actions; choose the best interventions for the patient; and then individualize standardized interventions to meet the patient’s unique needs.
Difficulty: Moderate
Nursing Process: Planning
Client Need: Safe and Effective Nursing Care
Cognitive Level: Analysis
PTS: 1
- The nurse is using electronic care planning. He enters the patient’s nursing diagnosis into the computer and chooses desired outcomes. He has validated his data, diagnosis, and goals. When he considers the list of interventions that the program generates, he sees that none of them fits this patient’s individual needs. What should the nurse do?
| a) | Reject them all and type in appropriate interventions. |
| b) | Select the interventions from the program that are most suitable. |
| c) | Ask another nurse to assess the patient and give her recommendation. |
| d) | Restart the computer; it is probably a program malfunction. |
ANS: A
The nurse can reject all the suggested interventions if they do not address patient needs. Nearly all computer programs have a screen that allows you to type in interventions and nursing orders. It is the nurse’s responsibility to choose interventions: He cannot abdicate this responsibility and let the computer “choose.” As a professional, this nurse has already validated the data, nursing diagnosis, and goals, so he can feel reasonably certain that there is nothing wrong with the plan to that point. Although consultation with other nurses may be a wise and prudent step to take at times, the nurse caring for the patient would likely have the most familiarity with the healthcare needs and is in a better position to make sound judgments than another nurse who does not know the patient. Therefore, it might not be productive or efficient to consult another nurse or restart the computer.
Difficulty: Moderate
Nursing Process: Planning
Client Need: Safe and Effective Nursing Care
Cognitive Level: Analysis
PTS: 1
- The nurse is completing her plan of care for a patient with congestive heart failure. In performing a direct-care nursing intervention the nurse will:
| a) | Collaborate with the physician for further medication orders |
| b) | Instruct the patient about low sodium and low fat diets |
| c) | Refer the patient to the cardiac rehabilitation program for a home-care exercise program |
| d) | Consult with physical therapist for cardiac rehabilitation exercises |
ANS: B
Direct-care interventions are performed through interactions with the client. Examples are physical care, emotional support, and teaching. An indirect-care intervention is an activity performed away from the client on behalf of the client. Indirect-care interventions include consulting with other healthcare team members, making referrals, advocating, and managing the environment.
Difficulty: Moderate
Nursing Process: Interventions
Client Need: Safe and Effective Nursing Care
Cognitive Level: Application
PTS: 1
- Which of the following best describes evidence-based practice?
| a) | Tool developed by a healthcare organization for its own use to guide best nursing practice |
| b) | An approach that uses the best scientific data to guide nursing practice |
| c) | Nurses who uses clinical judgment and expertise to guide nursing practice |
| d) | A method of practice that uses tradition and folklore interventions to guide practice |
ANS: B
Evidence-based practice is an approach that uses firm scientific data rather than anecdote, tradition, intuition, or folklore in making decisions about medical and nursing practice. In nursing, it includes blending clinical judgment and expertise with the best available research evidence and patient characteristics and preferences. A tool developed by a healthcare organization is usually in the form of a clinical pathway. These pathways are usually written per research evidence but not always.
Difficulty: Moderate
Nursing Process: Interventions
Client Need: Safe and Effective Nursing Care
Cognitive Level: Analysis
PTS: 1
- The nurse is caring for a 55-year-old male smoker on the medical-surgical unit. The patient states, “I’d really like some help in quitting smoking.” As part of her intervention plan she includes a smoking cessation class. What type of intervention is the nurse performing?
| a) | Wellness |
| b) | Prevention |
| c) | Assessment |
| d) | Treatment |
ANS: A
A smoking cessation class is an example of a health promotion or wellness intervention to promote a client’s efforts to achieve a higher level of wellness. Treatment interventions treat disorders, relieve symptoms, and carry out medical orders. Assessment interventions detect changes in the client’s condition and detect potential problems. Prevention interventions are used to help prevent complications.
Difficulty: Moderate
Nursing Process: Interventions
Client Need: PHSI
Cognitive Level: Comprehension
PTS: 1
- Which of the following is the best example of a well-written nursing order?
| a) | Provide emotional support to patient and family as needed. |
| b) | Bathe patient every day. |
| c) | Follow fluid restriction of 1,500 mL per day. |
| d) | Insert Foley catheter if patient has not voided within 8 hours. |
ANS: D
A well-written nursing order includes: Date, subject, action verb, time and limits, and a signature. The best example is the nursing order to insert a Foley catheter if the patient has not voided in 8 hours. This example provides the most information and direction for the nurse, as it contains the subject, action verb, time frame, and limits. The remaining options do not provide enough direction and information for the nurse, as they are vague and nonspecific
Difficulty: Moderate
Nursing Process: Interventions
Client Need: PHSI
Cognitive Level: Analysis
PTS: 1
- Which of the following is the best example of a well-written nursing order?
| a) | Administer pain medication 30 minutes prior to physical therapy exercises. |
| b) | Teach patient how to give insulin injections prior to discharge. |
| c) | The nurse will assess vital signs and report changes as needed. |
| d) | Consider patient and family cultural preferences in diet order. |
ANS: A
A well-written nursing order includes date, subject, action verb, time frame, limits, and a signature. The best example is the nursing order to administer pain medications within 30 minutes prior to physical therapy. This example provides the most information and direction for the nurse as it contains the subject, action verb, time frame, and limits. The remaining options do not provide enough direction and information for the nurse as they are vague and nonspecific.
Difficulty: Moderate
Nursing Process: Interventions
Client Need: PHSI
Cognitive Level: Analysis
PTS: 1
MULTIPLE RESPONSE
- Which statement(s) about nursing interventions is/are true? Select all that apply.
| a) | The responsibility of writing nursing orders cannot be delegated to the LPN/LVN. |
| b) | The best nursing interventions are based on tradition. |
| c) | Nursing interventions should be individualized and culturally sensitive. |
| d) | Standardized nursing interventions improve care for a specific client. |
ANS: A, C
Some nursing interventions and activities can be delegated to the LPN/LVN or nursing assistive personnel (NAP); however, writing nursing orders is the responsibility of the registered nurse. Nursing interventions should always be individualized and culturally sensitive. Whenever possible, nursing interventions should be based on scientific evidence, not tradition. Standardized interventions are not customized to improve care for a specific client.
Difficulty: Moderate
Nursing Process: Interventions
Client Need: Safe and Effective Nursing Care
Cognitive Level: Application
PTS: 1
- The nurse has completed the plan of care for her patient with a medical diagnosis of Gall Bladder Disease. In selecting nursing interventions that will best serve to help the patient achieve the desired goals, the nurse will consider which of the following? Select all that apply.
| a) | Age of the patient |
| b) | Patient abilities and preferences |
| c) | Education levels of the nursing staff |
| d) | Medical orders |
ANS: A, B, C, D
Nursing interventions are formulated to assist the patient in achieving the desired goals. In doing so, the nurse must consider patient abilities and preferences, the education, experience, and capabilities of the nursing staff, the resources available, medical orders, and institutional policies and procedures: Therefore all options are applicable.
Difficulty: Moderate
Nursing Process: Planning Interventions
Client Need: Safe and Effective Nursing Care
Cognitive Level: Application
PTS: 1
- The nurse is selecting nursing interventions for her patient with diabetes. The nurse will select interventions using which resources available to her? Select all that apply.
| a) | A standardized list of interventions |
| b) | Interventions generated based on her knowledge base and past experiences |
| c) | Traditional interventions that seem to have worked in the past |
| d) | Only those interventions that agree with patient preferences |
ANS: A, B
In selecting nursing interventions, a nurse has many resources available to her. One can select from a standardized list such as the NIC, standardized care plans, agency protocols, nursing texts, journals, and other professional nurses. Additionally, a nurse can generate her own list of interventions based on her knowledge base and experience. When possible, it is always best to choose interventions based on research and scientific principle. Traditional interventions can be used but they should be interventions that are supported by research as opposed to “seeming” to have worked. Patient preferences and directions are always considered when possible; however, the nurse cannot use only those interventions based on patient direction and preference.
Difficulty: Moderate
Nursing Process: Planning Interventions
Client Need: Safe and Effective Nursing Care
Cognitive Level: Application
PTS: 1
- Which of the following best describe the primary goal(s) of evidence-based practice? Select all that apply.
| a) | Identify the most effective treatments for disease processes, conditions, or problems |
| b) | Identify the most cost-effective treatments for disease processes, conditions, or problems |
| c) | Include all patient and family preferences in guiding nursing practice |
| d) | Create standardized clinical pathways for healthcare organizations |
ANS: A, B
Evidence-based practice (EBP) is an approach that uses firm scientific data rather than anecdote, tradition, intuition, or folklore in making decisions about medical and nursing practice. In nursing, it includes blending clinical judgment and expertise with the best available research evidence and patient characteristics and preferences. The goal of EBP is to identify the most effective and cost-effective treatments for a particular disease, condition, or problem. In using EBP, the nurse considers patient preferences; however, this is not the goal of EBP.
Difficulty: Moderate
Nursing Process: Planning
Client Need:
Cognitive Level: Analysis
PTS: 1
COMPLETION
- Nurses use a five-step process in selecting the best nursing interventions for their patients. Using the five-step process in selecting the best nursing interventions, arrange the list on the left in the correct order of completion on the right. (Enter the number of each step in the proper sequence, do not use commas.)
1). Review the desired outcomes/goals.
2). Identify several actions or interventions.
3). Individualize standardized interventions.
4). Review the nursing diagnosis.
5) Choose the best interventions for the patient.
ANS:
4 1 2 5 3
The following five-step process will assist the nurse in selecting the best interventions: Review the nursing diagnosis, review the desired outcomes/goals, identify several actions or interventions, choose the best interventions for the patient, and finally individualize standardized interventions.
Difficulty: Moderate
Nursing Process: Planning Interventions
Client Need: Safe and Effective Nursing Care
Cognitive Level: Analysis
PTS: 1
Chapter 7. Nursing Process: Implementation & Evaluation
MULTIPLE CHOICE
- A psychiatrist prescribes oral aripiprazole 10 mg daily for a client with schizophrenia. This medication is unfamiliar to the nurse, and she cannot find it in the hospital formulary or other references. How should she proceed?
| a) | Administer the medication as ordered. |
| b) | Hold the medication and notify the prescriber. |
| c) | Consult with a pharmacist before administering it. |
| d) | Ask the patient’s RN for information about the medication. |
ANS: C
The nurse must recognize when she does not have the knowledge or skill needed to implement an order. Because the nurse is unfamiliar with the medication, that does not mean she should hold it and delay patient treatment. It is wisest to first consult with the pharmacist for information before administering the medication to ensure safe practice. Administering the medication as ordered, without knowing its expected actions and side effects, at the least prevents adequate reassessment; at the most, it is dangerous. Holding the medication and notifying the prescriber prevents the client from receiving timely treatment—many drugs are less effective if a consistent schedule is not maintained. Asking another nurse to administer the medication is also unsafe because it cannot be assumed that the other nurse has the correct knowledge. In addition, the nurse caring for the client must assess for adverse reactions to the medication.
Difficulty: Moderate
Nursing Process: Implementation
Client Need: Safe and Effective Care
Cognitive Level: Analysis
PTS: 1
- Which task can be delegated to nursing assistive personnel (NAP)?
| a) | Turn and reposition the patient every 2 hours. |
| b) | Assess the patient’s skin condition. |
| c) | Change pressure ulcer dressings every shift. |
| d) | Apply hydrocolloid dressing to the pressure ulcer. |
ANS: A
The nurse can delegate turning the client every 2 hours to the nursing assistive personnel. Assessing the client’s skin condition, changing pressure ulcer dressings, and applying a hydrocolloid dressing to a pressure ulcer are all interventions that require nursing knowledge and judgment.
Difficulty: Moderate
Nursing Process: Implementation
Client Need: Safe and Effective Care
Cognitive Level: Application
PTS: 1
- A physician orders an indwelling urinary catheter for a client who is mildly confused and has been combative. How should the nurse proceed?
| a) | Ask a colleague for help, because the nurse cannot safely perform the procedure alone. |
| b) | Gather the equipment and prepare it before informing the client about the procedure. |
| c) | Obtain an order to restrain the client before inserting the urinary catheter. |
| d) | Inform the primary provider that the nurse cannot perform the procedure because the client is confused. |
ANS: A
Before the nurse begins a procedure, she should review the care plan and look at the orders critically. Because this client is confused, she should ask a colleague to assist with the procedure to prevent undue stress for the client and nurse. The client should be informed about the procedure before the nurse gathers the equipment. Gathering the equipment and bringing it into the room before explaining the procedure might cause the client anxiety. Restraining the client should be done only as a last resort and to prevent client injury. Informing the primary provider that the procedure cannot be performed because the client is confused is inappropriate because the procedure can very likely be done with assistance.
Difficulty: Moderate
Nursing Process: Implementation
Client Need: Safe and Effective Care
Cognitive Level: Analysis
PTS: 1
- Before inserting a nasogastric tube, the nurse reassures the client. Reassuring the client requires which type of nursing skill?
| a) | Psychomotor |
| b) | Interpersonal |
| c) | Cognitive |
| d) | Critical thinking |
ANS: B
Reassuring the client is an interpersonal skill. Inserting the nasogastric tube requires psychomotor skills. Checking catheter placement after insertion requires cognitive and psychomotor skills. Assessing whether there is an indication for the nasogastric tube requires critical thinking skills.
Difficulty: Moderate
Nursing Process: Implementation
Client Need: PHI
Cognitive Level: Comprehension
PTS: 1
- The nurse is caring for a client who was newly diagnosed with type 2 diabetes mellitus. Which intervention by the nurse best promotes client cooperation with the treatment plan?
| a) | Teaching the client that he must lose weight to control his blood sugar |
| b) | Informing the client that he must exercise at least three times per week |
| c) | Explaining to the client that he must come to the diabetic clinic weekly |
| d) | Determining the client’s main concerns about his diabetes |
ANS: D
Determining the client’s main concerns promotes cooperation with the treatment regimen. For example, if the client is concerned about paying for diabetic monitoring equipment, he may disregard any teaching about the procedure. Although it is often important for a diabetic client to exercise and lose weight to control blood sugar levels, the client must want to do both. He will not exercise or lose weight simply because he is told to do so. The nurse must assess the client’s support systems and resources, not merely tell him he must come to the diabetic clinic weekly. Some clients do not have access to transportation and, therefore, could not come to the clinic without social service intervention. Remember that knowledge does not necessarily change behavior.
Difficulty: Moderate
Nursing Process: Planning Interventions
Client Need: PHSI
Cognitive Level: Analysis
PTS: 1
- Which statement accurately describes delegation?
| a) | Transferring authority to another person to perform a task in a selected situation |
| b) | Collaborating with other caregivers to make decisions and plan care |
| c) | Scheduling treatments and activities with other departments |
| d) | Performing a planned intervention from a critical pathway |
ANS: A
Delegation is the transfer to another person of the authority to perform a task in a selected situation—the person delegating retains accountability for the outcome of the activity. Collaboration is described as working with other caregivers to plan, make decisions, and perform interventions. Coordination of care involves scheduling treatments and activities with other departments. Implementation is the process of performing planned interventions.
Difficulty: Easy
Nursing Process: Implementation
Client Need: Safe and Effective Care
Cognitive Level: Knowledge
PTS: 1
- Which statement by the nurse best demonstrates clear communication to nursing assistive personnel (NAP) about delegating a task?
| a) | “Record how the patient’s intake and output of fluids, please” |
| b) | “Take the patient’s temperature, pulse, respirations, and blood pressure every 2 hours today.” |
| c) | “Take the patient’s temperature every 4 hours; notify me if it is greater than 100.5°F (38.1°C).” |
| d) | “Assist the patient with all of her meals so she will take in more calories.” |
ANS: C
Clear communication about a task (such as “Take the patient’s temperature . . . ”) tells the NAP exactly what the task is, the specific time at which it needs to be done, and the method for reporting the results to the registered nurse. The other options are vague and leave room for misinterpretation.
Difficulty: Moderate
Nursing Process: Implementation
Client Need: Safe and Effective Care
Cognitive Level: Analysis
PTS: 1
- Who is responsible for evaluating the outcome of a task delegated to the nursing assistive personnel (NAP)?
| a) | Nurse who delegated the task |
| b) | LPN working with the NAP |
| c) | Unit nurse manager |
| d) | Charge nurse for the shift |
ANS: A
The nurse who delegates the task is responsible for supervising and evaluating the outcomes of tasks performed by the NAP. Another registered nurse, such as a staff nurse, nurse manager, or charge nurse, can answer questions and provide help, if necessary.
Difficulty: Easy
Nursing Process: Implementation
Client Need: Safe and Effective Care
Cognitive Level: Knowledge
PTS: 1
- Which criterion might be used in structure evaluation?
| a) | “Staff refrains from sharing computer passwords.” |
| b) | “Healthcare provider washes hands with each client contact.” |
| c) | “A defibrillator is present on each client care area.” |
| d) | “Nurse verifies client identification before initiating care.” |
ANS: C
The criterion that states “A defibrillator is present on each client care area” is associated with structure evaluation. “Refrains from sharing computer passwords,” “Washes hands before each client contact,” and “Verifies client identification before initiating care” are criteria associated with process evaluation.
Difficulty: Moderate
Nursing Process: Evaluation
Client Need: Safe and Effective Care
Cognitive Level: Analysis
PTS: 1
- Which of the following is a client outcome criterion?
| a) | Central venous catheter site infection does not occur (90% of cases). |
| b) | Client will sit out of bed in the chair for 20 minutes three times per day. |
| c) | Postoperative phlebitis does not occur (95% of cases). |
| d) | Falls in the facility will reduce by 2% this quarter. |
ANS: B
A client outcome criterion states the client health status or behaviors one wishes to effect. “Client will sit out of bed . . .” is a client outcome criterion. The other options are examples of organizational criteria used to evaluate the quality of care throughout the institution.
Difficulty: Moderate
Nursing Process: Evaluation
Client Need: Safe and Effective Care
Cognitive Level: Application
PTS: 1
- When should the nurse collect evaluation data for this expected outcome? “Patient will maintain urine output of at least 30 mL/hour.”
| a) | At the end of the shift |
| b) | Every 24 hours |
| c) | Every 4 hours |
| d) | Every hour |
ANS: D
The nurse should collect evaluation data as defined in the expected outcome. For instance, in this case, the nurse would check the patient’s urine output every hour because the goal statement specifies an hourly rate (30 mL/hour). The unit of measurement in the goal guides how often the nurse would reassess the patient.
Difficulty: Easy
Nursing Process: Evaluation
Client Need: PHSI
Cognitive Level: Application
PTS: 1
- Which type of client-centered evaluation is performed at specific, scheduled times?
| a) | Intermittent |
| b) | Ongoing |
| c) | Terminal |
| d) | Process |
ANS: A
Intermittent evaluation is performed at specific times; it enables the nurse to judge the progress toward goal achievement and to modify the plan of care as needed. Ongoing evaluation is performed while implementing, immediately after an intervention, or with each client contact; these are not necessarily scheduled events. Terminal evaluation is performed at the time of discharge. It describes the client’s health status and progress toward goals at that time. Process evaluation focuses on the manner in which care is given. It may be performed at specific times, but it is not considered a client-centered evaluation.
Difficulty: Easy
Nursing Process: Evaluation
Client Need: Safe and Effective Care
Cognitive Level: Knowledge
PTS: 1
- Which of the following is the most valid criterion for determining the status of a patient’s anxiety at discharge? The patient:
| a) | Has a relaxed facial expression |
| b) | Reports that he feels more relaxed today |
| c) | Shows no physiological signs of anxiety (e.g., pallor) |
| d) | Asks no further questions about home care |
ANS: B
A criterion is considered valid when it measures what it is intended to measure. Because anxiety is subjective (perceived by the patient), the best measure of anxiety is what the patient says about it. A relaxed facial expression and other physiological signs might or might not show the level of anxiety. Relaxation might occur, for example, because the patient is sleeping or falling asleep. The fact that a patient is not asking questions about his surgery could mean that he has adequate knowledge about the topic; it would not indicate the presence or absence of anxiety. All of the options except what the patient states could be measuring something other than anxiety.
Difficulty: Difficult
Nursing Process: Evaluation
Client Need: PSI
Cognitive Level: Application
PTS: 1
- The nurse works with the respiratory therapist to administer a patient’s breathing treatments. He reports the patient’s breathing status and tolerance of the treatment to the primary care provider. The nurse then discusses with the patient the options for further treatment. This is an example of:
| a) | Delegation |
| b) | Collaboration |
| c) | Coordination of care |
| d) | Supervision of care |
ANS: B
Collaboration means working with other caregivers to plan, make decisions, and perform interventions. Delegation is the transfer to another person of the authority to perform a task in a selected situation. Coordination of care involves scheduling treatments and activities with other departments, putting together all the patient data to obtain “the big picture.” Supervision is the process of directing, guiding, and influencing the outcome of an individual’s performance of an activity or task.
Difficulty: Moderate
Nursing Process: Evaluation
Client Need: Safe and Effective Care
Cognitive Level: Application
PTS: 1
- The nurse reviews the patient chart and sees a physician prescription for a new medication. The nurse is able to clearly read the medication name but the dose is not legible. What is the best action by the nurse?
| a) | Contact the physician for clarification. |
| b) | Ask another nurse to read the order. |
| c) | Ask the unit secretary to read the order. |
| d) | Contact the pharmacist to read the order. |
ANS: A
As a nurse, you are obligated ethically and legally to clarify or question orders that you believe to be unclear, incorrect, or inappropriate. In this case, the nurse should contact the physician to clarify the order, as it is not legible. It is inappropriate to ask the secretary or another nurse to read the order as they may read it incorrectly.
Difficulty: Moderate
Nursing Process: Implementation
Client Need: Safe and Effective Care
Cognitive Level: Application
PTS: 1
- The second-year nursing student is in her clinical rotation on a medical-surgical unit. What is the most appropriate strategy that the student can use to assist her in organizing and prioritizing patient care for the day?
| a) | Ask the nurse what tasks need to be completed for the day |
| b) | Make a time-sequenced “to do” list for her activities for the day |
| c) | Ask the instructor what needs to be completed for the day |
| d) | Ask the patient what needs to be completed for the day |
ANS: B
Because a nurse will be providing care for more than one patient on each shift, it is important to make a time-sequenced work plan or work sheet to prioritize patient care for the day. Many institutions have forms that can be used or one may need to write his/her own list of “things to do” in the order of need of completion. This is the best strategy this student can use. Asking the nurse or instructor will not assist the student in developing her own strategy for the future or in staying organized throughout the day. The patient is not a reliable source as not every patient is aware of what needs to be “completed” for the day.
Difficulty: Moderate
Nursing Process: Implementation
Client Need: Safe and Effective Care
Cognitive Level: Application
PTS: 1
- The nurse is preparing to insert a Foley catheter for her patient. What is the best strategy for the nurse to use to perform this insertion in a timely and efficient manner?
| a) | Call another nurse to assist with the procedure |
| b) | Gather all supplies and equipment before entering the patient room |
| c) | Instruct and explain the procedure to the patient |
| d) | Check the patient’s schedule for the day for the most convenient time |
ANS: B
Gathering all the supplies and equipment before entering a patient’s room is the best strategy to ensure that work is completed in an efficient and timely manner. This strategy will also help in preventing stress to the patient that may occur when a nurse is interrupted by needing to go to a supply room to get a needed item. Healthcare resources are scarce and staffing may not be conducive or feasible in having extra personnel available. Instructing and explaining a procedure to a patient is good practice and usually completed prior to any procedure for the purpose of patient cooperation and understanding. This is will not usually assist the nurse in completing a procedure in an efficient and timely manner.
Difficulty: Moderate
Nursing Process: Implementation
Client Need: Safe and Effective Care
Cognitive Level: Application
PTS: 1
- The nurse reviews a nursing order for a patient who is 4 days post-operative after hip surgery. It reads: Assist patient in bathing each morning. The nurse assesses the patient and notes that the patient is independent in bathing. What should the nurse do next?
| a) | Assist with the bath as ordered |
| b) | Delegate the bath to the nursing assistant |
| c) | Discontinue the nursing order on the plan of care |
| d) | Collaborate with the nurse who originally wrote the order |
ANS: C
After assessing and evaluating patient progress, the nurse will use her conclusions about goal achievement to decide whether to continue, modify, or discontinue the nursing order on the plan of care. In this item, the nurse has assessed patient independence and therefore can discontinue this nursing order from the plan of care.
Difficulty: Moderate
Nursing Process: Evaluation
Client Need: PHI
Cognitive Level: Application
PTS: 1
- Which of the following is the best example of the implementation phase of the nursing process?
| a) | Patient verbalizes pain is reduced from an 8 to a 3 after receiving pain medication. |
| b) | Nurse observes that patient has a small, quarter-sized skin tear over coccyx area. |
| c) | Nurse writes in the care plan: Patient requires 2 person assist with ambulation to bathroom. |
| d) | Nurse inserts Foley catheter after reporting to physician patient’s inability to void. |
ANS: D
Implementation is the action phase of the nursing process. It involves thinking but the emphasis is on doing. During implementation, the nurse will perform or delegate planned interventions. In short, implementation is doing, delegating, and documenting. A patient verbalizing that pain is reduced after receiving pain medication is part of the evaluation phase. Observing or noticing a skin tear relates to assessment and evaluation of skin condition. Writing on the care plan of a patient requiring assistance to the bathroom is an example of assessment and planning.
Difficulty: Moderate
Nursing Process: Implementation
Client Need: Safe and Effective Care
Cognitive Level: Analysis
PTS: 1
- The certified nursing assistant (CNA) is feeding a patient and notes that the patient is having difficulty swallowing. She reports this to the primary registered nurse. What should the nurse do first?
| a) | Assign the task to a more experienced CNA |
| b) | Feed the patient herself |
| c) | Assess the patient and place on NPO status |
| d) | Call the primary care provider |
ANS: C
Feeding a patient is a delegatable task that a CNA can perform. However, once it is reported to the registered nurse that the patient is having difficulty swallowing, this becomes a safety issue that the registered nurse must address. This circumstance is then no longer delegatable for any CNA regardless of experience. The first action by the nurse is to assess the patient and place the patient on NPO status until a primary provider is notified for further orders.
Difficulty: Moderate
Nursing Process: Implementation
Client Need: Safe and Effective Care
Cognitive Level: Application
PTS: 1
- Which of the following nursing activities is most reflective of the evaluation phase of the nursing process?
| a) | Administering pain medication prior to changing a complex wound dressing |
| b) | Obtaining patient’s blood pressure 30 minutes after administering blood pressure medication |
| c) | Reporting that there have been three patient falls in the past month on the nursing unit |
| d) | Teaching the patient how to perform daily Accu-Cheks for blood sugar readings |
ANS: B
Evaluation is the final step of the nursing process. It is a planned, ongoing, systematic activity in which a nurse will make judgments about patient progress toward desired health outcomes, effectiveness of the nursing care plan, and the quality of nursing care in the healthcare setting. Evaluation data are collected after interventions are performed to determine whether patient goals were achieved. In this item, obtaining a patient’s blood pressure after administering blood pressure medications evaluates the patient’s response to the medication. Administering pain medication prior to performing a dressing change is an intervention, as is teaching a patient to perform an Accu-Chek. Reporting patient falls is part of the assessment process.
Difficulty: Moderate
Nursing Process: Evaluation
Client Need: Safe and Effective Care
Cognitive Level: Analysis
PTS: 1
MULTIPLE RESPONSE
- The nurse and nursing assistive personnel (NAP) are caring for a group of patients on the medical-surgical floor. For which of the following patients can the nurse delegate to the NAP the task of bathing? Select all that apply.
| a) | 75-year-old patient newly admitted with dehydration |
| b) | 65-year-old patient hospitalized for a stroke, whose blood pressure reading is 189/90 mm Hg |
| c) | 92-year-old patient with stable vital signs who was admitted with a urinary tract infection |
| d) | 56-year-old patient with chronic renal failure who has vital signs within his normal range |
ANS: A, C, D
The nurse should not delegate bathing of a client newly diagnosed with a stroke whose blood pressure is unstable or otherwise abnormal. This client requires the keen assessment and critical thinking skills of a registered nurse. The nurse can safely delegate the care of stable clients, such as the client admitted with dehydration, the client admitted with a urinary tract infection, or the client with chronic renal failure. Any client who is very ill or who requires complex decision making should be cared for by a registered nurse.
Difficulty: Difficult
Nursing Process: Implementation
Client Need: Safe and Effective Care
Cognitive Level: Analysis
PTS: 1
- Which of the following is the most appropriate task(s) to be delegated to the licensed practical nurse (LPN)? Select all that apply.
| a) | Administer oral pain medications |
| b) | Insert an indwelling (e.g., Foley) catheter |
| c) | Perform an admission assessment on a new patient |
| d) | Establish a new teaching plan for a diabetic patient |
ANS: A, B
The licensed practical nurse (LPN) can administer oral medications and insert a Foley catheter. LPNs can usually provide care to medically stable patients according to an established plan of care; they can give you feedback about patient responses for patients who are expected to respond predictably. Tasks you can usually assign to an LPN include administering some medications and oral medications, and in some instances, starting an IV infusion and administering plain IV solutions. Some tasks that cannot be delegated include creating or modifying nursing care plans. Performing an admission assessment on a newly admitted patient and establishing a teaching plan are usually the responsibility of the registered nurse, as these tasks requires professional nursing judgment and critical thinking.
Difficulty: Difficult
Nursing Process: Planning Implementation
Client Need: Safe and Effective Care
Cognitive Level: Application
PTS: 1
- The nurse has just completed wound care on her patient who has a large abdominal wound. What should the nurse do soon after this is completed? Select all that apply.
| a) | Assess the patient’s response to the procedure |
| b) | Teach the patient about the procedure |
| c) | Document the procedure in the nursing progress notes |
| d) | Ask the patient to assist in the wound care at the next scheduled dressing change |
ANS: A, C
After giving care, the nurse needs to assess and record the nursing activities and the patient’s responses. This is the final step in the implementation process. Documentation is a mode of communication among the members of the health team, so it needs to be done soon after finishing the procedure. It provides the information the nurse needs to evaluate the patient’s health status and nursing care plan. The implementation phase ends when the nurse documents the nursing actions and evolves into evaluation as the nurse documents patient responses to the interventions. Teaching the patient and asking the patient to assist in wound care as a part of that teaching do not need to be done right away.
Difficulty: Difficult
Nursing Process: Implementation
Client Need: Safe and Effective Care
Cognitive Level: Application
PTS: 1
