Fundamentals: Chapter 19,
Implementing Nursing Care Exam
2022
1.Implementation - Correct Answer- The fourth step of the nursing process,(formally
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begins after the nurse develops a plan of care) the nurse initiates the interventions
that are most likely to achieve the goals and expected outcomes needed to support
or improve the client's health status.
2.Nursing intervention - Correct Answer- Is any treatment, based on clinical
judgment and knowledge, that a nurse performs to enhance client outcomes.
Ideally the interventions a nurse uses are evidenced based, providing the most
current, up-to-date, and effective approaches for managing patient problems.
Interventions include direct and indirect care aimed at individuals, families, and/or
the community.
3.Direct care (interventions) - Correct Answer- Are treatments performed through
interactions with patient's.
Ex: Medication administration, insertion of an intravenous (IV) infusion, or counseling
during a time of grief.
4.Indirect care (interventions) - Correct Answer- Are treatments performed away
from the patient but on behalf of the patient or group of patient's.
Ex: Actions for managing patient's environment (e.g. safety and infection control),
documentation, and interdisciplinary collaboration.
5.Critical Thinking in Implementation - Correct Answer- Critical thinking is necessary
to consider the complexity of interventions, including the number of alternatives
approaches and the amount of time available to act.
Before implementing a planned intervention, use critical thinking to confirm whether
the intervention is correct and still appropriate for the patient's clinical situation.
6.Identify the factors that should be considered when making decisions about
implementation - Correct Answer- a. Review the set of all possible interventions for
the patient's problem
b. Review all of the possible consequences associated with each possible nursing
action
c. Determine the probability of all possible consequences
d. Make a judgment of the value of that consequence to the patient
7.Standard nursing interventions - Correct Answer- Many patients have common
health care problems; thus standardized interventions for these health problems
make it quicker and easier for nurses to intervene.
->Nurse/Physician initiated standardized interventions- Clinical guidelines or
protocols, Preprinted (standing) orders, and Nursing Interventions Classification
(NIC) interventions.
->Professional level- The American Nurses Association (ANA) defines standards of
professional nursing practice, which include standards for the implementation step of
the nursing process.
8.Clinical practice guideline - Correct Answer- Or protocol is a document that guides
decisions and interventions for specific health care problems or conditions.
(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.
9.Standing orders - Correct Answer- Is a preprinted document containing orders for
the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures
for patients with identified clinical problems.
10.Nursing Interventions Classification (NIC) interventions - Correct Answer- Offer a
level of standardization to enhance communication of nursing care across settings
and to compare outcomes
11.What are the five preparatory activites for implementation of safe and effective
nursing care. - Correct Answer- 1. Reassessing the patient
2. Reviewing & Revising the existing nurse care plan
3. Organizing resources and care delivery
4. Anticipating and preventing complications
5. Implementation nursing interventions
12. "Reassessing the patient" - Correct Answer- Reassessing the patient is a
continuous process that occurs each time you interact with a patient; you collect new
data, identify a new patient need, and modify the care plan
13. " Reviewing & Revising the existing nurse care plan" - Correct Answer- If the
patient's status has changed and the nursing diagnosis and related nursing
interventions are no longer appropriate, modify the nursing care plan
14. "Organizing resources and care delivery" - Correct Answer- Organizing
resources and care delivery involves organization of equipment, skilled personnel,
and the environment. This makes timely, efficient, skilled patient care possible.
15. "Anticipating and preventing complications" - Correct Answer- Risks to patients
come from both the illness and the treatments
16. "Implementation skills" - Correct Answer- Implementation skills includes cognitive
(application of critical thinking in the nursing process), interpersonal (trusting
relationship, level of caring and communication) and psychomotor skills (integration
of cognitive and motor activities).
17.Activities of daily living (ADLs) - Correct Answer- Activities usually performed in
the course of a normal day (ambulation, eating, dressing, bathing, grooming)
18.Instrumental activities of daily living include (IADL's) - Correct Answer- Skills such
as shopping, preparing meals, writing checks, taking medications..... [Show Less]