1. A nurse is implementing interventions for a group of patients. Which actions are nursing interventions? (Select all that apply.)
a. Order chest x-ray
... [Show More] for suspected arm fracture.
b. Prescribe antibiotics for a wound infection.
c. Reposition a patient who is on bed rest.
d. Teach a patient preoperative exercises.
e. Transfer a patient to another hospital unit.
ANS: C, D, E
A nursing intervention is any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes. Repositioning, teaching, and transferring a patient are examples of nursing interventions.
Ordering a chest x-ray and prescribing antibiotics are examples of medical interventions performed by a health care provider.
2. A nurse is providing nursing care to a group of patients. Which actions are direct care interventions? (Select all that apply.)
a. Ambulating a patient
b. Inserting a feeding tube
c. Performing resuscitation
d. Documenting wound care
e. Teaching about medications
ANS: A, B, C, E
All of the interventions listed (ambulating, inserting a feeding tube, performing resuscitation, and teaching) are direct care interventions involving
patient and nurse interaction, except documenting wound care.
Documenting wound care is an example of an indirect intervention.
3. A nurse is preparing to carry out interventions. Which resources will the nurse make sure are available? (Select all that apply.)
a. Equipment
b. Safe environment
c. Confidence
d. Assistive personnel
e. Creativity
ANS: A, B, D
A nurse will organize time and resources in preparation for implementing nursing care. Most nursing procedures require some equipment or supplies. Before performing an intervention, decide which supplies you need and determine their availability. Patient care staff (assistive personnel) work together as patients’ needs demand it. A patient’s care environment needs to be safe and conducive to implementing therapies. Confidence and creativity are needed to provide safe and effective patient care; however, these are critical thinking attitudes, not resources.
4. Which interventions are appropriate for a patient with diabetes and poor wound healing? (Select all that apply.)
a. Perform dressing changes twice a day as ordered.
b. Teach the patient about signs and symptoms of infection.
c. Instruct the family about how to perform dressing changes.
d. Gently refocus patient from discussing body image changes. Administer medications to control the patient’s blood sugar as
e. ordered.
ANS: A, B, C, E
Nursing priorities include interventions directed at enhancing wound healing. Teaching the patient about signs and symptoms of infection will help the patient identify signs of appropriate wound healing and know when the need for calling the health care provider arises. Performing dressing changes, controlling blood sugars through administration of medications, and instructing the family in dressing changes all contribute to wound healing. As long as a patient is stable and alert, it is appropriate to allow family to assist with care. The patient should be allowed to discuss body image changes.
1. A nurse determines that the patient’s condition has improved and has met expected outcomes. Which step of the nursing process is the nurse exhibiting?
a. Assessment
b. Planning
c. Implementation
d. Evaluation
ANS: D
Evaluation, the final step of the nursing process, is crucial to determine whether, after application of the first four steps of the nursing process, a patient’s condition or well-being improves and if goals have been met.
Assessment, the first step of the process, includes data collection. Planning, the third step of the process, involves setting priorities, identifying patient goals and outcomes, and selecting nursing interventions. During implementation, nurses carry out nursing care, which is necessary to help patients achieve their goals.
2. A nurse completes a thorough database and carries out nursing interventions based on priority diagnoses. Which action will the nurse take next?
a. Assessment
b. Planning
c. Implementation
d. Evaluation
ANS: D
Evaluation, the final step of the nursing process, is crucial to determine whether, after application of the first four steps of the nursing process, a patient’s condition or well-being improves. Assessment involves gathering information about the patient. During the planning phase, patient outcomes are determined. Implementation involves carrying out appropriate nursing interventions.
3. A new nurse asks the preceptor to describe the primary purpose of
evaluation. Which statement made by the nursing preceptor is most accurate?
A. “An evaluation helps you determine whether all nursing interventions
were completed.”
B. “During evaluation, you determine when to downsize staffing on
nursing units.”
C. “Nurses use evaluation to determine the effectiveness of nursing
care.”
D. “Evaluation eliminates unnecessary paperwork and care planning.”
ANS: C
Evaluation is a methodical approach for determining if nursing implementation was effective in influencing a patient’s progress or condition in a favorable way. During evaluation, you do not simply determine whether nursing interventions were completed. The evaluation process is not used to determine when to downsize staffing or how to eliminate paperwork and care planning.
4. After assessing the patient and [Show Less]