Nur1025 - T2 - Ch. 19 - Implementing Nursing Care

Front 1

C1. The nurse enters a pt's room and finds the pt was incontinent of liquid stool. The pt has recurrent redness in the perineal area, and there is concern that he is developing a pressure ulcer. The nurse cleanses the pt, 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 pt to recommend skin care measures. Which of the following describe the nurse's actions.

1. The application of the skin barrier is a dependent care measure.
2. The call to the ostomy and wound care specialist is an indirect care measure.
3. The cleansing of the skin is a direct care measure.
4. The application of the skin barrier is a direct care measure.

Back 1

2. 3. 4.

Front 2

C2. During the implementation step of the nursing process, a nurse reviews and revises the nursing plan of care. Place the following steps of review and revision in the correct order:

1. Review the care plan.
2. Decide if the nursing interventions remain appropriate.
3. Reassess the pt.
4. Compare assessment findings to validate existing nursing diagnoses.

Back 2

#1. 3 - Reassess the pt.
#2. 1 - Review the care plan.
#3. 4 - Compare assessment findings to validate existing nursing diagnoses.
#4. 2 - Decide if the nursing interventions remain appropriate.

Front 3

C3 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:

1. Have the nurse colleague check the dose with her before giving the med.
2. Consult with a pharm to obtain knowledge about the purpose of the drug, the action, and the potential side effects.
3. Ask the nurse colleague to admin the med to her pt.
4. Admin the med as prescribed and on time.

Back 3

2.

Front 4

C4. When does implementation begin as the fourth step of the nursing process?

1. During the assessment phase
2. Immediately in some critical situations.
3. After the care plan has been developed
4. After there is mutual goal setting between nurse and pt

Back 4

3.

Front 5

C5. Before consulting with a physician about a pt's need for urinary catheterization, the nurse considers the fact that the pt 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 pt was voiding normally. This scenario is an example of which implementation skill?

1. Cognitive
2. Interpersonal
3. Psychomotor
4. Consultative

Back 5

1. Cognitive

Front 6

C6. The nurse enters a pt's room, and the pt asks if he can get out of bed and transfer to a chair. The nurse takes precautions to use safe pt handling techniques and transfers the pt. This is an example of which physical care technique?
1. Meeting the pt's expressed wishes
2. Indirect care measure
3. Protecting a pt from injury
4. Staying organized when implementing a procedure

Back 6

3.

Front 7

C7. 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).
1. Following the procedural guideline for IV insertion
2. Seeking necessary knowledge about the steps of the procedure from a more experienced nurse
3. Showing confidence in performing the correct IV insertion technique
4. Being sure that the IV dressing covers the IV site completely.

Back 7

2. 3.

Front 8

C8. Which steps does the nurse follow when he or she is asked to perform an unfamiliar procedure. (Select all that apply).

1. Seeks necessary knowledge.
2. REassesses the pt's condition
3. Collects all necessary equipment
4. Delegates the procedure to a more experienced staff member

Back 8

1., 3., 5.

Front 9

C9. Indirect or Direct intervention?

A. A nurse checks the monthly performance improvement report on fall occurrences on a unit. ___
B. A nurse discusses with the pt exercise restrictions to follow on return home. _____
C. A nurse consults with a dietitian about a pt's therapeutic diet food choices. _____
D. A nurse administers a tube feeding. _______
E. A Nurse assists a colleague in applying a complex dressing to a pt's wound. ______

Back 9

A. Indirect
B. Direct
C. Indirect
D. Direct
E. Direct

Front 10

C10. A nurse is talking with a pt who is visiting a neighborhood health clinic. The pt came to the clinic for repeated Sx of a sinus infection. During their discussion the nurse checks the pt'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?

1. Tertiary
2. Direct care
3. Primary
4. Secondary

Back 10

3. Primary

Front 11

C11.A nurse is orienting a new graduate nurse to the unit. The graduate nurse asks, "Why do we have standing orders for cases when pts develop life-threatening arrythmias? Is not each pt's situation unique?" What is the nurse's best answer?

1. Standing orders are used to meet our phys preferences.
2. Standing orders ensure that we are familiar with evidence-based guidelines for care of arrythmias.
3. .... allow us to respond quickly and safely to a rapidly changing clinical situation.
4. ... Minimize the documentation we have to provide.

Back 11

3.

Front 12

C12. A nurse on a cancer unit is reviewing and revising the written plan of care for a pt who has the nursing Dx of nausea. Place the following steps in their proper order:

1. The nurse revises approaches in the plan for controlling environmental factors that worsen nausea.
2. The nurse enters data in the assessment column showing new information about the pt's nausea.
3. The nurse adds the current date to show that the Dx of nausea is still relevant.
4. The nurse decides to use the pt's self-report of appetite and fluid intake as evaluation measures.

Back 12

#1. 2 - Nurse enters data in the assessment column showing new info about the pt's nausea.
#2. 3 - The nurse adds the current date to show that the diagnosis of nausea is still relevant.
#3. 1 - The nurse revises approaches in the plan for controlling environmental factors that worsen nausea.
#4. 4 - Nurse decides to use the pt's self-report of appetite and fluid intake as evaluation measures.

Front 13

C13. When a nurse properly positions a pt and admin an enema solution at the correct rate for the pt's tolerance, this is an example of what type of implementation skill?

Back 13

4. Pscyhomotor

Front 14

C14. The nurse reviews a pt's medical record an sees that tube feedings are to begin after a feeding tube is inserted. In recent past experiences the nurse has seen pts on the unit develo 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?

1. Preventive
2. Controlling for an adverse reaction
3. Consulting
4. Counseling

Back 14

2. Controlling for an adverse reaction

Front 15

C15. A nurse is starting on the evening shift and is assigned to care for a pt with a diagnosis of impaired skin integrity related to pressure and moisture on the skin.. The pt is 72 yo and had a stroke. Pt weighs 250 lbs and is difficult to turn. As the nurse makes decisions about how to implement skin care for the pt, which of the following actions does the nurse implement? (Select all that apply.)
!. Review the set of all possible nursing interventions for each pt's problem
2. Review all possible consequences associated with each possible nursing action
3. Consider own level of competencey
4. Determine the probability of all possible consequences.

Back 15

1. 2. 4.

Front 16

W1. Define the 4th step of the nursing process.

Back 16

Implementation begins after the nurse develops a care plan based on clear and relevant nursing Dx. The interventions are designed to achieve the goals and expected outcomes needed to support/improve the pt's health status.

Front 17

W2a. Define "Nursing intervention."

W2b. Direct care.

W2c. Indirect care.

Back 17

a. Nursing intervention is any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance pt outcomes.
b. Direct care = treatments performed through interactions with pts.
c. Indirect care = treatments performed away from the pt but on behalf of the pt.

Front 18

W3. ID the factors that should be considered when making decisions about implementation.

Back 18

1. Review the set of all possible interventions for the pt's problem.
2. Review all of the possible consequences associated with each possible nursing action.
3. Determine the probability of all possible consequences.
4. Make a judgment of the value of that consequence to the pt.

Front 19

W4. Clinical practice guideline.

Back 19

A clinical practice guideline or protocol is a document that guides decisions and interventions.

Front 20

W5. Standing order.

Back 20

A standing order is a preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, or diagnostic procedures for pts with identified clinical problems

Front 21

W6. Nursing Interventions Classification (NIC) interventions.

Back 21

Interventions offer a level of standardization to enhance communication of nursing care across settings and to compare outcomes.

Front 22

W7a. Name the 5 prep activities for implementation of safe and effective nursing care. .

Back 22

Reassessing the pt
Reviewing and revising the existing nursing care plan
Organizing resources and care delivery
Anticipating and preventing complications
Implementation skills

Front 23

W7. Reassessing the pt. (Explain)

Back 23

A continuous process that occurs each time you interact with a pt; you collect new data, ID a new pt need, and modify the care plan.

Front 24

W8. Reviewing and revising the existing nursing care plan. (Explain)

Back 24

if the pt's status has changed and the nursing Dx and related nursing interventions are no longer appropo, modify the nursing care plan.

Front 25

W9. Organizing resources and care delivery. (Explain)

Back 25

Organizing resources and care delivery involves organization of equipment, skilled personnel, and the environment.

Front 26

W10. Anticipating and preventing complications (Explain).

Back 26

Risks to patients come from both the illness and the treatments.

Front 27

W11. Implementation skills. (explain)

Back 27

Implementation skills include cognitive (application of crit thinking in the NP), interpersonal (trusting relationship, level of caring and communication) and psychomotor skills (integration of cognitive and motor activities).

Front 28

W12. Define ADLs.

Back 28

Activities of Daily Living.
Usu. performed in the course of a normal day - ambulation, eating, dressing, bathing, and grooming.

Front 29

W13. Instrumental activities of daily living (IADLs) include?

Back 29

Skills such as shopping, prep meals, writing checks, and taking meds.

Front 30

W14. Physical care techniques include?

Back 30

INvolve the safe and competent adminstration of nursing procedures.

Front 31

W15. Lifesaving measures are?

Back 31

Physical care techniques that are used when a pt's physiological or psychological state is threatened.

Front 32

W16. Counseling is ?

Back 32

A direct care method that helps the pt use a problem-solving process to recognize and manage stress and to facilitate interpersona relationships.

Front 33

W17. The focus of teaching is?

Back 33

The focus of teaching is intellectual growth or the acquisition of new knowledge or psychomotor skills

Front 34

W18. An adverse reaction is?

Back 34

A harmful or unintended effect of med, diagnostic test, or therapeutic intervention.

Front 35

W19. Preventive nursing actions are?

Back 35

Promote health and prevent illness to avoid the need for acute or rehabilitative health care.

Front 36

W20. Define interdisciplinary care plan.

Back 36

Represents the contributions of all disciplines caring for the pt.

Front 37

W21. Explain the responsibility of the nurse for delegating and supervising others.

Back 37

Noninvasive and frequently repetitive interventions can be assigned to assistive personnel. The nurse is responsible for ensuring that each task is appropriately assigned and is completed according to the standard of care.

Front 38

W22. Patient adherence is?

Back 38

When pts and families invest time in carrying out required treatments to achieve pt goals.

Front 39

W23. Which of the following is not true of standing orders?
!. Standing orders are commonly found in critical care & community health settings.
2. ... are approved and signed by the HCP in charge of care before implementation.
3. ... nurses have the legal protection to intervene appropro in the pt's best insterest.
4. ....the nurse relies on the HCP judgment to determine if the intervention is appropriate.

Back 39

4. The nurse needs to exercise good judgment and decision making before actually delivering any interventions.

Front 40

The nursing care plan calls for the pt, a 300-lb woman, to be turned every 2 hurs. The pt is unable to assist with turning. The nurse knows that she may hurt her back if she attempts to turn the pt by herself. The nurse should:

1. Turn the pt herself.
2. Ask another nurse to help her turn the pt.
3. Rewrite the care plan to eliminate the need for turning
4. Ignore the intervention related to turning in the care plan.

Back 40

2. Certain nursing situations require you to obtain assistanced by seeking additional personnel, knowledege, or nursing skills. You will need assistance with this pt to help turn and position the pt safely.

Front 41

Mrs. Kay comes to the family clinic for birth control. The nurse obtains a health history and performs a pelvic examination and Pap smear. The nurse is functioning according to:

Back 41

1. guides decisions and interventions for specific health care problems

Front 42

Mary Jones is a newly diagnosed pt with diabetes. The nurse shows Mary how to administer an injection. This intervention activity is:
1. Teaching
2. Managing
3. Counseling
4. Communnicating

Back 42

1. An acquisition of new knowledge or pscyhomotor skill