Nursing Process: Planning Interventions

Identify the choice that best completes the statement or answers the question.

____ 1. Which of the following nursing interventions is an indirect-care intervention?

1)
Emotional support
2)
Teaching
3)
Consulting
4)
Physical care

____ 2. Which nursing intervention is considered an independent intervention?

1)
Administering 1 liter of dextrose 5% in normal saline solution at 100 mL/hour
2)
Encouraging the postoperative client to perform coughing and deep breathing exercises
3)
Explaining his diet to the client; then communicating the teaching with the dietitian
4)
Administering morphine sulfate 2 mg IV to the client with postoperative pain

____ 3. 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?

1)
Collaborative
2)
Interdependent
3)
Dependent
4)
Independent

____ 4. The nurse is performing preoperative teaching for a client who is scheduled for surgery in the morning. The client does not presently have any respiratory problems. The nurse’s teaching plan includes coughing and deep breathing exercises. Which type of nursing intervention is the nurse performing?

1)
Health promotion
2)
Treatment
3)
Prevention
4)
Assessment

____ 5. Which standardized intervention vocabulary was designed specifically for community health nurses?

1)
Omaha System
2)
Clinical Care Classification
3)
Nursing Interventions Classification
4)
International Classification for Nursing Practice

____ 6. 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?

1)
7/12/10 Encourage use of the incentive spirometer every hour while the client is awake—D. Goodman, RN
2)
By 7/12/10, uses incentive spirometer 10 times every hour while awake to 1000 mL
3)
Incentive spirometer hourly while awake
4)
Offer incentive spirometer to the client—J. Smith, RN

____ 7. A newly diagnosed diabetic client 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?

1)
Consulting the diabetic nurse educator for help with a teaching plan
2)
Making arrangements for the client to join a diabetic support group
3)
Demonstrating blood glucose monitoring and insulin administration to the client
4)
Consulting with the dietician about the client’s dietary concerns

____ 8. Which definition best describes a critical pathway?

1)
Standardized plan of care for frequently occurring conditions
2)
Systematically developed statement to assist practitioners and patients in decision making
3)
Systematic review of clinical evidence for an intervention
4)
Set of interrelated concepts that describes or explains something

____ 9. 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?

1)
Determine airway adequacy hourly and as needed
2)
Administer oxygen as needed
3)
Monitor arterial blood gas values
4)
Place the client in a high Fowler’s position

____ 10. Who is the primary decision maker when caring for healthy adult clients?

1)
Physician
2)
Family
3)
Client
4)
Nurse

____ 11. 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?

1)
Think of several interventions likely to achieve the desired outcomes.
2)
Review the problem and etiology of the nursing diagnosis.
3)
Choose the best interventions for the patient.
4)
Review the goals she has written.

____ 12. 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 the program generates, he sees that none of them fit this patient’s individual needs. What should the nurse do?

1)
Reject them all and type in appropriate interventions.
2)
Select the interventions from the program that are most suitable.
3)
Ask another nurse to assess the patient and give her recommendation.
4)
Restart the computer; it is probably a program malfunction.

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

____ 1. Which statement(s) about nursing interventions is/are true? Select all that apply.

1)
The responsibility of writing nursing orders cannot be delegated to the LVN.
2)
The best nursing interventions are based on tradition.
3)
Nursing interventions should be individualized and culturally sensitive.
4)
Standardized nursing interventions improve care for a specific client.

____ 2. An 80-year-old resident in a long-term-care facility comes to the emergency department with dehydration. The nurse writes a diagnosis of Deficient Fluid Volume related to excessive fluid loss. An individualized nursing goal identified for this client is “The client will maintain urine output of at least 30 mL/hour.” Which nursing interventions would directly help achieve or evaluate the stated goal? Choose all that are correct.

1)
Measure and record urine output every hour; report an output of less than 30 mL/hour.
2)
Monitor skin turgor and moistness of mucous membranes every shift.
3)
Administer intravenous (IV) fluids as prescribed.
4)
Keep oral fluids within the patient’s reach and encourage the patient to drink.

Chapter 6. Nursing Process: Planning Interventions

Answer Section

MULTIPLE CHOICE

1. ANS: 3

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, advocacy, and managing the environment. Direct-care interventions include emotional support, patient teaching, and physical care.

PTS: 1 DIF: Easy REF: V1, pp. 102-103

KEY: Nursing process: Implementation | Client need: SASE | Cognitive level: Recall

2. ANS: 2

Encouraging the postoperative client to perform coughing and deep breathing exercises is an independent nursing intervention. An independent intervention is one that nurses are licensed to prescribe, perform, or delegate based on their skills and knowledge. Administering IV fluid or morphine sulfate are dependent interventions; they require an order from a physician or advanced practice nurse but are carried out by the nurse. Explaining to the client how sodium intake affects his heart failure and then communicating the teaching with the dietitian is an interdependent intervention, one that is carried out in collaboration with other healthcare team members.

PTS: 1 DIF: Moderate REF: V1, p. 103

KEY: Nursing process: Interventions | Client need: SASE | Cognitive level: Application

3. ANS: 4

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.

PTS: 1 DIF: Moderate REF: V1, p. 103

KEY: Nursing process: Interventions | Client need: Physiological Integrity | Cognitive level: Application

4. ANS: 3

The nurse is teaching the client coughing and deep breathing exercises, which help prevent postoperative pneumonia. Therefore, the nurse is utilizing 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.

PTS: 1 DIF: Moderate REF: V1, p. 107

KEY: Nursing process: Interventions | Client need: Physiological Integrity | Cognitive level: Application

5. ANS: 1

The Omaha System was designed specifically for community health nurses to use in caring for individuals, families, community groups, or entire communities. The Clinical Care Classification was developed for home health care. The Nursing Interventions Classification system is applicable in all settings, including home health and community nursing. The International Classification for Nursing Practice system was designed to describe nursing practice of individuals, families, and communities worldwide.

PTS: 1 DIF: Easy REF: V1, p. 112

KEY: Nursing process: Planning | Client need: SASE | Cognitive level: Recall

6. ANS: 1

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. Plus, 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.

PTS: 1 DIF: Moderate REF: V1, pp. 113-114

KEY: Nursing process: Planning | Client need: Physiological Integrity | Cognitive level: Application

7. ANS: 3

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.

PTS: 1 DIF: Moderate REF: V1, p. 102

KEY: Nursing process: Interventions | Client need: Physiological Integrity | Cognitive level: Application

8. ANS: 1

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 health care for a particular disease or procedure. Evidence reports are systematic reviews on 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.

PTS: 1 DIF: Easy REF: V1, p. 105

KEY: Client need: SECE | Cognitive level: Recall

9. ANS: 1

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.

PTS: 1 DIF: Difficult REF: V1, p. 107 | V1, p. 112

KEY: Nursing process: Planning | Client need: Physiological Integrity | Cognitive level: Analysis

10. ANS: 3

The client is the primary decision maker in the care of healthy clients. The nurse functions as a teacher and health counselor. The physician plays a role in health promotion and screening. The family may give input, but the client is the decision maker.

PTS: 1 DIF: Easy REF: V1, p. 113

KEY: Nursing process: Planning | Client need: Health Promotion | Cognitive level: Comprehension

11. ANS: 2

The process of choosing interventions is review the nursing diagnosis; 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.

PTS: 1 DIF: Moderate REF: V1, p. 108

KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis

12. ANS: 1

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 there is nothing wrong with the plan to that point. Although consultation with other nurses can be wise and prudent at times, the nurse caring for the patient would likely have the most familiarity with the health care 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.

PTS: 1 DIF: Moderate REF: V1, p. 112

KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis

MULTIPLE RESPONSE

1. ANS: 1, 3

Some nursing interventions and activities can be delegated to the LVN or UAP; 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.

PTS: 1 DIF: Moderate REF: V1, pp. 103-104

KEY: Nursing process: Interventions | Client need: SASE | Cognitive level: Application

2. ANS: 1, 3, 4

Measuring and recording urine output allow for direct evaluation of the goal “urine output 30 mL/hour.” Administering IV fluids adds fluid to correct dehydration, improve blood flow through the kidneys, and increase urine production. Intake of oral fluids has the same effect. Monitoring skin turgor and mucous membranes are ways to assess for dehydration, but it does not directly apply to the goal of maintaining urine output. It is an intervention aimed at the etiology of this nursing diagnosis, rather than the problem.

PTS: 1 DIF: Moderate

REF: V1, p. 107; High-level question; answer not given verbatim

KEY: Nursing process: Interventions | Client need: Physiological Integrity | Cognitive level: Analysis