Nursing Process: Planning Interventions

MULTIPLE CHOICE

     1.   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

Page 106

PTS:   1

     2.   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

Page 107

PTS:   1

     3.   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

Pages 106-107

PTS:   1

     4.   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

Page 116

PTS:   1

     5.   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

Page 116

PTS:   1

     6.   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

Page106

PTS:   1

     7.   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

Pages 110-111

PTS:   1

     8.   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

Page 116

PTS:   1

     9.   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

Pages 110-112

PTS:   1

   10.   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

Page 113

PTS:   1

   11.   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

Page 106

PTS:   1

   12.   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

Page 108

PTS:   1

   13.   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

Page 116

PTS:   1

   14.   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

Page 116

PTS:   1

   15.   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

Page 116

PTS:   1

MULTIPLE RESPONSE

     1.   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

     2.   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

Page 106

PTS:   1

     3.   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

Pages 110-112

PTS:   1

     4.   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

Page 108

PTS:   1

COMPLETION

     1.   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

Pages 111-113

PTS:   1