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Get faster at matching terms Terms in this set (23)In which step of the nursing process does the nurse provide nursing care interventions to patients? A. Assessment ANS: C The nurse defines a clinical guideline or protocol as a A. Guideline to follow that replaces the nursing care plan. ANS: B The standing orders for a patient include acetaminophen (Tylenol) 650 mg every 4 hours prn for headache. After assessing the patient, identifying the need for headache relief, and determining that the patient has not had Tylenol in the past 4 hours, the nurse A. Notifies the health care provider to obtain a verbal order. ANS: C Before implementing any intervention, the nurse uses critical thinking to A. Determine whether an intervention is correct and appropriate for the given situation. ANS: A Which of the following is a nursing intervention? A. The patient will ambulate in the hallway twice this shift using crutches correctly. ANS: C A patient recovering from a leg fracture after a fall states that he has dull pain in the affected leg and rates it as a 7 on a 0 to 10 scale. The patient is not able to walk around in the room with crutches because of leg discomfort. What is the priority nursing intervention for this patient? A. Assist the patient to walk in the room with crutches. ANS: D The nurse is caring for a patient who requires a complex dressing change. While in the patient's room, the nurse decides to change the dressing. What does the nurse do just before changing the dressing? A. Assesses the patient's readiness for the procedure ANS: A A patient visiting with family members in the waiting area tells the nurse that his stomach is not feeling good. Before intervening, what should the nurse do? A. Ask the patient to return to his room so the nurse can inspect his abdomen. ANS: A A newly admitted patient who is morbidly obese asks the nurse to assist her to the bathroom for the first time. What should the nurse do first? A. Ask for at least two other assistive personnel to come to the room. ANS: D Which of these interventions, to be included in the plan of care, is appropriate for the patient outcome that states, "The patient will verbalize a pain level at 3 or below on a 0 to 10 scale throughout this shift."? A. Medicate the patient immediately after all procedures. ANS: C What is the first intervention included on any patient's plan of care? A. Determine patient outcomes and goals. ANS: C Vital signs for a patient reveal a high blood pressure of 187/100. Orders state to notify the health care provider for diastolic blood pressure greater than 90. What is the nurse's first action? A. Assess the patient for other symptoms or problems, and then notify the health care provider. ANS: A Which intervention is most appropriate for a patient who has a new onset of chest pain? A. Administer a prn medication for pain.
ANS: B Which is the appropriate initial intervention for the nursing diagnostic statement Impaired skin integrity related to poor wound healing? A. Reinforce the wound dressing as needed with 4 × 4 gauze. ANS: D The nurse establishes trust and talks with a school-aged patient before administering injections. This nurse is demonstrating which type of implementation skill? A. Cognitive ANS: B The nurse inserts an intravenous catheter using the correct technique and following the recommended steps according to standards of care and hospital policy. This is demonstrating which type of implementation skill? A. Cognitive ANS: C A nurse employed in a staff development department is providing an in-service for other nurses to educate them about the Nursing Interventions Classification (NIC) system. During the in-service, which of the following statements made by one of the nurses in the room requires the staff nurse to clarify the information provided? A. "This system can help medical students determine the cost of the care they provide." ANS: A The nurse is intervening for an identified nursing diagnosis of Caregiver role strain. Which direct care nursing intervention is most appropriate? A. Assisting with activities of daily living ANS: B The nurse is intervening for an identified nursing diagnosis of Risk for infection. Which direct care nursing intervention is most appropriate? A. Teaching the family proper handwashing technique ANS: A Which of the following are nursing interventions? (Select all that apply.) a. Order chest x-ray for suspected humerus fracture. ANS: C, D
Which of the following are direct care interventions? (Select all that apply.) a. Turning a patient ANS: A, B, C, E Before implementing care, the nurse needs to ensure that which resources are available? (Select all that apply.) a. Equipment ANS: A, B, C, D Which interventions are appropriate for the nursing diagnosis Impaired tissue integrity related to poor wound healing secondary to diabetes? (Select all that apply.) a. Teach the patient about signs and symptoms of infection. ANS: A, C, D, E Sets with similar termsChapter 19: Implementing Nursing Care19 terms maegene NR 226 Exam 1 - Review Questions95 terms kmarie422 Sets found in the same folderFundamentals I & II: Chapter 16: Nursing Assessment20 terms JanviPatel2 Fundamentals II: Chapter 17: Nursing Diagnosis19 terms JanviPatel2 Fundamentals II: Chapter 18: Planning Nursing Care20 terms JanviPatel2 Fundamentals II: Chapter 20: Evaluation21 terms JanviPatel2 Other sets by this creatorChapter 19 - Pediatrics Exam Prep57 terms JanviPatel2 NR446: Collaborative Healthcare: Quiz #138 terms JanviPatel2 Nursing Fundamentals Exam 1 Practice Test129 terms JanviPatel2 Chapter 17: Health Promotion Of Adolescent and Fam…24 terms JanviPatel2 Other Quizlet setsBUL FINAL Unit 1133 terms chiara_goodman9 Keystone Literature17 terms nickblack04 Rsh. meth 1 chapter 1 definitions32 terms emilykoye1 psychology chapter 320 terms jdemarco43 Related questionsQUESTION A 5-year old client has a type of dermatitis. Which type of dermatitis diagnosis would the nurse expect to find in the medical record? 2 answers QUESTION what are the landmarks for the deltoid muscle? 15 answers QUESTION What three things influence the capacity of the blood to carry oxygen? 15 answers QUESTION What is the large opening at the base of the skull? 15 answers What is the nursing process when providing patient care?The steps of the nursing process include assessment, nursing diagnosis, planning, intervention, and evaluation. These five steps are used cyclically and repeatedly during patient care. The sequence must be followed from start to finish to ensure that the needs of the patient are addressed (Morris, 2006).
What are the 5 stages of the nursing process?The common thread uniting different types of nurses who work in varied areas is the nursing process—the essential core of practice for the registered nurse to deliver holistic, patient-focused care. Assessment. ... . Diagnosis. ... . Outcomes / Planning. ... . Implementation. ... . Evaluation.. What is the implementation stage of the nursing process?The implementation phase of the nursing process is when the nurse puts the treatment plan into effect. It involves action or doing and the actual carrying out of nursing interventions outlined in the plan of care. This typically begins with the medical staff conducting any needed medical interventions.
What are the 3 nursing interventions?There are typically three different categories for nursing interventions: independent, dependent and interdependent.
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In which step of the nursing process does the nurse provide nursing care interventions to patients?
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