Homework Lance
1. The nurse is working with postoperative clients on a surgical unit. One aspect of care is manipulation of the client’s environment. This involves the nurse:
1.
Repositioning the client q2h
2.
Removing clutter from the client’s room
3.
Delegating ambulation of clients to the nursing assistant
4.
Providing pain medication to the client before a dressing change
ANS: 2
Making rooms free of clutter is an example of manipulating the environment to create safe surroundings. The remaining options are examples of the organization of care and personnel.
DIF: A REF: 282 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
2. The client is given an injection of an antibiotic. Shortly afterwards the client reports hives and itching. The nurse administers an antihistamine to counteract the effect of the antibiotic. The nurse is using which one of the following intervention methods?
1.
Preventive measures
2.
Assisting with ADLs
3.
Preparing for special procedures
4.
Compensation for adverse reactions
ANS: 4
Nursing actions that control for adverse reactions reduce or counteract the reaction, such as administering an antihistamine after an allergic reaction to a medication. Preventive measures promote health and prevent illness while assisting with ADLs and preparing for special procedures are direct care measures.
DIF: A REF: 283-284 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
3. The client is scheduled to receive Coumadin (an anticoagulant) at 9:00 AM. His morning laboratory results show him to have a high partial thromboplastin time (PTT). His nurse decides to withhold the Coumadin. Which step of the implementation process is she using?
1.
Reassessing the client
2.
Stating an expected outcome
3.
Revising the nursing diagnosis
4.
Modifying the nursing care plan
ANS: 4
The nurse is modifying the nursing care plan. Data have been updated to reflect the client’s current status of an elevated PTT; nursing diagnoses and specific interventions are revised. In this case, the revised intervention is withholding the Coumadin. By gathering further assessment data and revising nursing interventions, the nurse is modifying the nursing care plan.
DIF: A REF: 282 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
4. The nurse notes that a narcotic is to be administered “per epidural cath.” The nurse; however, does not know how to perform this procedure. Which aspect of the implementation process should be followed?
1.
Seek assistance
2.
Reassess the client
3.
Use interpersonal skills
4.
Critical decision making
ANS: 1
If a nurse does not know how to perform a procedure, he or she should seek assistance. Information about the procedure is obtained from the literature and the agency’s procedure book. All equipment necessary for the procedure is collected. Finally, another nurse who has completed the procedure correctly and safely provides assistance and guidance. Reassessing the client is a partial assessment that may focus on one dimension of the client or on one system. Interpersonal skills are used to develop a trusting relationship, express a level of caring, and communicate clearly with the client, family, and health care team. Critical decision making is used when the nurse implements the care plan using the knowledge bases necessary for care planning and then completing the planned interventions most effectively.
DIF: A REF: 284 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
5. The nurse recognizes the discharge needs of a client following a hip replacement. This is an example of which type of nursing skill?
1.
Cognitive
2.
Interactive
3.
Psychomotor
4.
Communication
ANS: 1
Cognitive skills involve the application of nursing knowledge. Being able to identify a client’s discharge needs is a cognitive skill. Interactive skills are interpersonal skills such as developing a trusting relationship and communicating effectively. Psychomotor skills involve the integration of cognitive and motor skills such as with administering an injection. Effective communication is an interpersonal skill. The nurse communicates with the client and family when providing client teaching and emotional support. The nurse communicates with the health care team to achieve client outcomes.
DIF: A REF: 284 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
6. An example of a cognitive nursing skill is:
1.
Providing a soothing bed bath
2.
Communicating with the client and family
3.
Giving an injection to the client per the physician’s orders
4.
Recognizing the potential complications of a blood transfusion
ANS: 4
Cognitive skills involve the application of nursing knowledge. Understanding normal and abnormal physiological and psychological responses is a cognitive skill, as in recognizing the potential complications of a blood transfusion. Providing a soothing bed bath involves both interpersonal skills and psychomotor skills. The nurse who provides a soothing bed bath is expressing a level of caring that is an interpersonal skill. The nurse who provides a soothing bed bath is also using a psychomotor skill in performing the bed bath correctly. Communicating with the client and family is an example of an interpersonal skill. Giving an injection to the client is a psychomotor skill.
DIF: A REF: 284 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
7. An enterostomal nurse shows a client’s significant other how to assist with the supplies for the ostomy and how to manipulate the ostomy equipment. In demonstrating this technique to the client’s significant other, the nurse is using what type of nursing skill?
1.
Affective
2.
Cognitive
3.
Interactive
4.
Psychomotor
ANS: 4
Psychomotor skills involve the integration of cognitive and motor activities, such as in providing ostomy care. Cognitive skills involve the application of nursing knowledge. Knowing the rationale for therapeutic interventions, understanding normal and abnormal physiological and psychological responses, and being able to identify client learning and discharge needs all require cognitive skills. Interpersonal skills are used when the nurse interacts with clients, their families, and other health care team members. Effective communication is an example of an interpersonal skill. Affective means pertaining to an emotion or mental state.
DIF: A REF: 284 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
8. For a client with a nursing diagnosis of impaired physical mobility related to bilateral arm casts, the nurse should select which of the following methods of nursing intervention?
1.
Teaching
2.
Counseling
3.
Compensating for adverse reactions
4.
Assisting with activities of daily living (ADLs)
ANS: 4
A client with bilateral arm casts has a temporary need for assistance with ADLs. Counseling is a direct care method that helps the client use a problem-solving process to develop new attitudes and feelings. It does not meet the physical need for assistance with ADLs. Teaching is an implementation method used to present correct principles, procedures, and techniques of health care to clients and to inform clients about their health status. Compensating for adverse reactions means the nurse takes action to reduce or counteract the reaction, such as by administering an antihistamine when a client has an allergic reaction to a medication. Assisting with ADLs would be compensating for the client’s impaired mobility.
DIF: A REF: 285 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
9. The plan of care offers a number of different types of nursing interventions that may be incorporated in. An example of a nurse implemented specific life-saving measure is:
1.
Administering analgesics
2.
Restraining a violent client
3.
Initiating stress-reduction therapy
4.
Teaching the client how to take his/her pulse rate
ANS: 2
Restraining a violent client is an example of a life-saving measure to protect the client. The purpose of a life-saving measure is to restore physiological or psychological equilibrium. Administering analgesics is an example of physical care techniques. It is not a life-saving measure. Initiating stress-reduction therapy is an example of a counseling technique. Teaching the client how to take his or her pulse rate is an example of the nursing intervention of teaching. The focus is for the client to obtain new knowledge or psychomotor skills.
DIF: A REF: 285 OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
10. To provide optimum care, a nursing intervention should be based on:
1.
An appropriate nursing diagnosis
2.
Subjective and objective client data
3.
Sound clinical judgment and knowledge
4.
Identified physical and psychosocial needs of the client
ANS: 3
The assessment data direct the nurse in the formulation of a client-specific care plan grounded within clear, relevant nursing diagnoses and directed towards appropriate, attainable client outcomes. A nursing intervention is any treatment, based upon clinical judgment and knowledge that a nurse performs to enhance client outcomes. Ideally, the interventions a nurse uses are evidence-based, providing the most current, up-to-date, and effective approaches for client problems. Interventions include both direct and indirect care measures, aimed at individuals, families, and/or the community.
DIF: C REF: 279 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
11. Which of the following interventions is the best example of an indirect intervention directed towards client safety?
1.
Checking on a restrained client every 15 minutes
2.
Performing hand hygiene between client contacts
3.
Including the diagnosis at risk for injury related to falls to a client’s care plan
4.
Turning on a night light to illuminate the path to the bathroom
ANS: 4
Indirect care interventions are treatments performed away from the client but on behalf of the client or group of clients. For example, indirect care measures include actions for managing the client’s environment (e.g., safety and infection control), documentation, and interdisciplinary collaboration. Directly impacting the light level in a client’s room to minimize the risk for falls is the best example of a safety-oriented indirect care intervention. Including a nursing diagnosis regarding falls would also be an example of an indirect care intervention but it is not as actively affecting the client’s safety. Checking a restrained client is a direct care intervention because it involves actual client contact, while performing hand hygiene is directed more towards infection control than safety.
DIF: C REF: 287 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
12. Which of the following interventions best reflects the nurse’s understanding of direct care interventions regarding a cognitively impaired client’s need for social interaction?
1.
Arranging for the client to attend a “sing along” in the dayroom
2.
Helping the client place a long distance telephone call to his daughter
3.
Turning the client’s television on when his or her favorite program is playing
4.
Talking about the client’s favorite sport’s team while redressing his or her wound
ANS: 4
Direct care interventions are treatments performed through interactions with clients. Actively engaging in a conversation with the client is the best direct care intervention and so demonstrates the best understanding of the concept. Facilitating interaction does not have as much impact as being actively involved. Turning on the TV is an example of an indirect care intervention.
DIF: C REF: 285 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
13. The primary reason for the establishment of standing orders is to:
1.
Provide appropriate nursing autonomy in settings where client needs can change rapidly
2.
Facilitate adequate care when direct contact with a primary health care provider is not immediately possible
3.
Allow nurses to provide certain routine therapies without first notifying the primary health care provider
4.
Afford the client interventions that reflect the appropriate standard of care in the absence of a primary health care provider
ANS: 1
Licensed prescribing physicians or health care providers in charge of care at the time of implementation approve and sign standing orders. These orders are common in critical care settings and other specialized practice settings where clients’ needs change rapidly and require immediate attention, thus providing for nursing autonomy to assess and implement appropriate care.
DIF: C REF: 281 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
14. Which of the following statements best reflects the nurse’s understanding of the function of client reassessment?
1.
“The client’s blood pressure is lower this morning than it was yesterday morning.”
2.
“30 minutes after receiving his pain medication, the client evaluated his pain at 3 out of 10.”
3.
“Turning the client every 2 hours has helped in the healing of the pressure ulcer on his coccyx.”
4.
“Since the client has been ambulating to the bedroom without difficulty, I’ll walk with him to the dayroom after dinner.”
ANS: 4
When reassessment results in the collection of new data that identify a new client need, the care plan is modified. Modification of a plan also occurs when a client’s health care need shows improvement or is resolved. The other options reflect recognition of a change in the client’s condition but do not reflect an alteration of the care plan.
DIF: C REF: 281-282 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
15. Which of the following statements made by a nurse practitioner best reflects an understanding of the availability of clinical practice guidelines?
1.
“Clinical guidelines are so very helpful in providing the most up-to-date nursing care.”
2.
“I’m sure we could get a team together and develop a pressure ulcer prevention protocol or search sites for established protocols.”
3.
“I am particularly impressed by the type 2 diabetic guidelines posted on the National Guidelines Clearinghouse (NGC) site.”
4.
“I’m told that for gerontological issues, the Gerontological Nursing Interventions Research Center (GNIRC) is the primary resource site.”
ANS: 3
There are clinical practice guidelines already developed by national health groups. These guidelines are readily available to any clinician or health care institution that wishes to adopt evidence-based guidelines in the care of clients with specific health problems. The best option reflects the nurse’s personal experience with a published protocol.
DIF: C REF: 281 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
16. The fundamental goal for the development of a protocol for care of a client who has had a myocardial infarction client is to:
1.
Implement care that has its basis in evidence-based practice
2.
Produce care plans that are specific to the individual client needs
3.
Improve the standard of care provided to the clients cared for on that unit
4.
Provide the staff on that unit with guidelines to ensure the delivery of quality care
ANS: 3
Clinicians within a health care agency sometimes choose to review the scientific literature and their own standard of practice to develop guidelines and protocols in an effort to improve their standard of care. All the other options are potential outcomes of the implementation of a protocol.
DIF: C REF: 281 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
17. Which of the following nursing actions is most likely a result of the nurse’s clinical experience?
1.
Placing an immobile client on a turning schedule
2.
Always assessing a client’s IV site before hanging a new bag of fluid
3.
Requesting that the nursing assistant have vital signs recorded by 0815
4.
Administering a pain medication 30 minutes before changing a burn dressing
ANS: 2
As a nurse gains clinical experience, he or she will be able to consider which interventions have worked previously, which have not, and why. The decision to check each IV site has become a practice standard for this nurse as a result of previous experiences with IV sites. The remaining options are either standards of care or facility/unit standards.
DIF: C REF: 280 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
18. Which of the following statements made by a new nursing graduate requires immediate follow-up by the nurse’s mentor?
1.
“Older clients with arthritis require additional time to complete to complete their own AM care.”
2.
“My client’s wife says he loves chocolate milk so I will order his dietary supplement in chocolate.”
3.
“My client just received some bad news regarding her tests. I’ll see if the chaplain can visit this evening.”
4.
“Teenage diabetics seem to have a more difficult time making good food choices in order to control their blood sugars.”
ANS: 3
The nurse delivers each intervention within the context of a client’s unique situation. It is an assumption that a client who has received “bad news” would want a visit from a clergy member. The other options represent statements relating to normal characteristics of a specific development stage, condition, or preference.
DIF: C REF: 279 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
19. A client reports to the nurse that the room is “too hot.” Which of the following nursing actions best reflects the nurse’s understanding of the therapeutic manipulation of the client’s environment?
1.
Bringing a portable fan into the room
2.
Assisting the client in the removal of excess clothing
3.
Offering to ambulate the client into the visiting lounge
4.
Closing the blinds to minimize the sunshine through the windows
ANS: 1
Although closing the blinds may manipulate the environment, it will always minimize the ambient light in the room. Cooling the room by introducing the fan will not impact any other aspect of the environment. It may not be appropriate for the client to remove clothing and leaving the room is only a temporary solution to the problem.
DIF: C REF: 282 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
20. Which of the following statements made by a new graduate nurse regarding the modification of a client’s care plan requires immediate follow-up by the nurse’s preceptor?
1.
“I will review the care plan before I do my charting.”
2.
“The client prefers to bathe at night, so that’s what I’ll do.”
3.
“I gave her a bed bath this morning, but she could really manage showering herself.”
4.
“The order reads clear liquids, but I hear good bowel sounds and she’s really hungry.”
ANS: 4
With the assessment data supporting advancement in diet, the new graduate should initiate a modification of the client’s nursing care plan because this directly impacts the client’s nutritional status. Although facilitating client independence is appropriate, this option does not have priority over the option impacting nutrition. The other options do not involve modification of the care plan.
DIF: C REF: 282 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
21. Which of the following statements regarding utilization of personnel made by a new graduate nurse requires immediate follow-up by the nurse’s mentor?
1.
“My LPN is really good with dressings, so I usually delegate them to her.”
2.
“I always take the time to ambulate a post op client the first time out of bed.”
3.
“I always try to help my nursing assistant with the clients who require a total bed bath.”
4.
“I have my nursing assistant take and document all vital signs and intake and outputs.”
ANS: 4
The nurse is responsible for determining whether to perform an intervention or to delegate it to another member of the nursing team. Assessment of a client directs the decision about delegation and not the intervention alone. Vital signs are important indicators of a client’s health status and the task should be delegated to ancillary personnel only when the client is in a stable condition; otherwise, the nurse should be responsible. The other options reflect responsible assignment of personnel.
DIF: C REF: 287 OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Safe, Effective Care Environment
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