Exam 19: Implementing Nursing Care

Which action indicates a nurse is using critical thinking for implementation of nursing care to patients?

A nurse is implementing interventions for a group of patients. Which actions are nursing interventions? (Select all that apply.)

Which initial intervention is most appropriate for a patient who has a new onset of chest pain?

Which action should the nurse take first during the initial phase of implementation?

The standing orders for a patient include acetaminophen 650 mg every 4 hours prn for headache. After assessing the patient, the nurse identifies the need for headache relief and determines that the patient has not had acetaminophen in the past 4 hours. Which action will the nurse take next?

A nurse is making initial rounds on patients. Which intervention for a patient with poor wound healing should the nurse perform first?

A nurse is reviewing a patient's care plan. Which information will the nurse identify as a nursing intervention?

A nurse is providing nursing care to patients after completing a care plan from nursing diagnoses. In which step of the nursing process is the nurse?

The nurse is intervening for a patient that has a risk for a urinary infection. Which direct care nursing intervention is most appropriate?

A nurse is providing nursing care to a group of patients. Which actions are direct care interventions? (Select all that apply.)

A newly admitted patient who is morbidly obese asks the nurse for assistance to the bathroom for the first time. Which action should the nurse take initially?

The nurse inserts an intravenous (IV) catheter using the correct technique and following the recommended steps according to standards of care and hospital policy. Which type of implementation skill is the nurse using?

A nurse is preparing to carry out interventions. Which resources will the nurse make sure are available? (Select all that apply.)

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. Which action will the nurse take just before changing the dressing?

The nurse is teaching a new nurse about protocols. Which information from the new nurse indicates a correct understanding of the teaching?

The nurse is intervening for a family member with role strain. Which direct care nursing intervention is most appropriate?

A patient recovering from a leg fracture after a fall reports having 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. Which nursing intervention is priority?

A patient visiting with family members in the waiting area tells the nurse "I don't feel good, especially in the stomach." What should the nurse do?

A staff development nurse is providing an inservice for other nurses to educate them about the Nursing Interventions Classification (NIC) system. During the inservice, which statement made by one of the nurses in the room requires the staff development nurse to clarify the information provided?

The nurse establishes trust and talks with a school-aged patient before administering an injection. Which type of implementation skill is the nurse using?