Chapter 14: Implementing

A school nurse notices that a female adolescent student is losing weight and decides to perform a focused assessment of her nutritional status to determine if she has an eating disorder. How should the nurse proceed?

A nurse is using the implementation step of the nursing process to provide care for patients in a busy hospital setting. Which nursing actions best represent this step?

Nurses use the Nursing Interventions Classification Taxoconomy structure as a resource when planning nursing care for patients. What information would be found in this structure?

A new RN is being oriented to a nursing unit that is currently understaffed and is told that the UAPs have been trained to obtain the initial assessment. What is the best response of the RN?

A nurse performs nurse-initiated nursing actions when caring for patients in a skilled nursing facility. Which are examples of these types of interventions?

A nurse is about to perform pin site care for a patient who has a halo traction device installed. What is the first nursing action that should be taken prior to performing this care?

A nurse develops a detailed plan of care for 16 year old female who is a new single mother of a premature infant. The plan includes collaborative care measures and home health care visits. When presented with the plan, the patient states "We will be fine on our own, I don't need any more care." What would be the nurse's best response?

An RN working on a busy hospital unit delegates patient care to an UAP. Which patient care could the nurse delegate to UAP?

A student is organizing clinical responsibilities for an 84-year old female patient who is diabetic and is being treated for foot ulcers. The patient tells the student "I need to have my hair washed before I can do anything else today. I am ashamed of the way I look." The patient's need include diagnostic testing, dressing changes, meal planning,, counseling, and assistance with hygiene. How would the nurse best prioritize this patient's care?

The nurse continues to collect data and to modify the plan of care as needed.

It is not important for the nurse to make rounds with other health care professionals and to read the results of consultations.

Nurses always monitor the patient's responses to the interventions.

It is critical to [blank_start]assess[blank_end] the patient carefully before initiating any [blank_start]nursing[blank_end] [blank_start]intervention[blank_end] to make sure that the plan of care is still responsive to the patient's [blank_start]needs[blank_end] and prioritized to the most pressing of those [blank_start]needs[blank_end].

Order [blank_start]sufficient[blank_end] [blank_start]supplies[blank_end] at the beginning of the shift for the care you expect to provide, and be thoughtful of the nurse who will follow you by leaving adequate supplies.

In [blank_start]every[blank_end] patient encounter, an important nursing intervention is ongoing [blank_start]data[blank_end] [blank_start]collection[blank_end].

Another vital nursing intervention, is ongoing [blank_start]risk[blank_end] [blank_start]management[blank_end].

While monitoring the patient's responses to the plan of care, nurses are also alert to the development of new [blank_start]problems[blank_end] that may result in the identification of new [blank_start]diagnoses[blank_end] or [blank_start]collaborative[blank_end] [blank_start]problems[blank_end].

When a patient does not follow the plan of care despite your best efforts, it is time to [blank_start]reassess[blank_end] the strategy.

Which nursing actions reflect the implementing step of nursing process?

Which of the following nursing interventions is most likely to be allowed w/in the parameters of a protocol or standing order?

Which of the following is a nursing intervention that facilitates life span care?

Which is the responsibility of the nurse in the nurse-health care team relationship?

The nurse ascertains that the client is failing to follow the plan that was collaboratively developed. Further investigation determines that the plan of care is not appropriate for this client. What is the nurse's next step in correcting the problem?

A nurse is preparing to educate a client about self-care after a cataract surgery. Which of the following would the nurse do first?

A nurse on duty finds that a client is anxious about the results of laboratory testing. Which intervention by the nurse reflects a supportive intervention?

Which are essential components for delegating nursing care?

Which nursing intervention is appropriate for a risk nursing diagnoses?

After learning about a client's limited financial resources and limited insurance benefits, the home care nurse modifies nursing interventions related to a client's care instructions. The nurse modifies the plan of care based upon which client variable?

The nurse is caring for a postoperative client who is receiving morphine sulfate for pain management. The nurse obtains the following vital signs. HR 74 RR 8 BP 114/68. After reviewing the nursing care plan and physician orders, the nurse administers naloxone (Narcan). What would allow the nurse to initiate this action?

The nurse is preparing to administer oxygen 3 Liters/minute via nasal cannula. The nursing student asks "What type of intervention is oxygen administration? What is the best response by the nurse?

A student nurse is performing a sterile dressing change on a client's abdominal incision. While establishing her sterile field, she drops the forceps on the floor. She is unable to continue with the dressing change because she has no extra supplies, and no one is present to bring new forceps. The student has failed to organize

Which of the following examples of nursing actions involve direct care of the client?

The nurse is attending a conference on evidence based practice. Which statement by the nurse indicates further education is needed?